12/3/18 Functions: ¨ ¨ ¨ DRUGS ACTING ON THE RESPIRATORY SYSTEM Brings oxygen into the body Allows for exchange of gases Leads to expulsion of carbon dioxide and other waste products By: April G. Marqueses-Obon, RN, MSN UPPER RESPIRATORY TRACT Structure and function of the respiratory system ¨ ¨ ¨ ¨ ¨ Pairs of SINUSES ¨ ¨ Mucus produced on the sinuses drains into the nasal cavity. From there, the mucus drains into the throat and is swallowed into the gastrointestinal tract, where stomach acid destroys foreign materials. Nose Mouth Pharynx Larynx Trachea PHARYNX and LARYNX ¨ Larynx contains the vocal cords and epiglottis 1 12/3/18 Receptors in the walls of trachea are stimulated Receptors in the walls in the nasal cavity are stimulated A central nervous system is initiated A central nervous system is initiated COUGH SNEEZE REFLEX Causes air to be pushed through the bronchial tree under tremendous pressure Forces foreign materials directly out or the system, opening it for more efficient flow of gas TRACHEA ¨ ¨ ¨ Trachea – the main conducting airway into the lungs. All of these tubes contain mucus-producing goblet cells and cilia to entrap any particles that may have escaped the upper protective mechanisms. The walls of the trachea and conducting bronchi are highly sensitive to irritation. MACROPHAGE Cleaning out the foreign irritant LOWER RESPIRATORY TRACT ¨ Mast cells are present in abundance and release of histamine, serotonin, adenosine triphosphate (ATP), and other chemicals to ensure rapid and intense inflammatory reaction to any cell injury. ¨ ¨ ¨ Bronchial tree Smallest brochioles Alveoli BRONCHIAL TUBES composed of 3 layers: cartilage, muscles and epithelial cells RESPIRATION GAS EXCHANGE (the act of breathing to allow gas exchange) ¨ ¨ Occurs in the alveoli Respiration ¤ The exchange of gases at the alveolar level ¨ The sac is able to stay open because of the surface tension of the cells is decreased by lipoprotein surfactant. ¨ Inspiratory muscles ¨ Vagus nerve ¤ ¤ ¨ Diaphragm, external intercostals, and abdominal muscles A predominantly parasympathetic nerve, plays a key role in stimulating diaphragm contraction and inspiration Sympathetic system ¤ Stimulation can lead to increased rate and depth of respiration and dilation of the bronchi to allow freer flow of air in the system 2 12/3/18 SUMMARY: ¨ ¨ ¨ ¨ Respiratory system has two parts: upper and lower respiratory tract. Gas exchanges occur in the alveoli. Nasal hairs, mucus-producing goblet cells, cilia, the superficial blood supply of the upper tract, and the cough and sneeze reflexes all work to keep foreign substances from entering the lower respiratory tract. Alveoli produce surfactant, which reduces surface tension, among other functions. Medulla controls respiration, which depends on a functioning muscular and a balance between the sympathetic and parasympathetic systems. Respiratory Pathophysiology 1. Common Cold Upper Respiratory Tract Conditions ¨ ¨ ¨ A number of viruses causes common cold. Mucus membranes become engorged with blood, tissues swells, and the goblets cells increase the production of mucus Sinus pain, nasal congestion, runny nose, sneezing, watery eyes, scratchy throat, and headache. Blocks the outlet of the eustachian tube ¤ Feelings of ear stuffiness and pain, more likely to develop ear infection (otitis media) 2. Seasonal/Allergic Rhinitis ¨ ¨ ¨ Inflammation of the nasal cavity, commonly called hay fever. Specific antigen (e.g. pollen, mold, dust) 3. Sinusitis ¨ ¨ Occurs when the epithelial lining of the sinus cavities becomes inflamed. Severe pain nasal congestion, sneezing, stuffiness, and watery eyes 3 12/3/18 4. Pharyngitis and Laryngitis ¨ Infections of the pharynx and the larynx Common bacteria or viruses Frequently seen in influenza ¨ Fever, muscle aches and pains, and malaise ¨ ¨ A. Antihistamines ¨ Block the release or action of histamine, a chemical released during inflammation that increases secretions and narrows airways. ¤ H1 receptor – when stimulated extravascular muscles, including those lining the nasal cavity, are constricted ¤ H2 receptor – when stimulated, an increase in gastric secretions occurs, which is a cause of PUD ¨ Designed to relieve respiratory symptoms and to treat allergies Drugs acting on the upper respiratory tract First-generation (drowsiness) ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ Therapeutic Actions and Indications ¨ ¨ ¨ ¨ Block the effects of histamine at the histamine-1 receptor sites, decreasing the allergic response. They also have anticholinergic (atropine-like) and antipruritic effects. Seasonal and perennial allergic rhinitis, allergic conjunctivitis, uncomplicated urticaria, and angioedema Allergic reactions to blood or blood products and adjunctive therapy in anaphylactic reactions Second-generation (less sedating) dipenhydramine (Benadryl) promethazine (Phenergan) brompheniramine (Bidhist) buclizine (Bucladin-S) cabinoxamine (Histex, Palgic) chlorpheneramine (AllerChlor) clemastine (Tavist) (p. 576) ¨ loratidine (Claritin) cetirizine (Zyrtec) desloratadine (Clarinex) azelastine (Astelin) fexofenadine (Allegra) ¨ levoceticizine (Xyzal) ¨ ¨ ¨ ¨ Pharmacokinetics ¨ Well absorbed orally, with an onset of 1 – 3 hours Metabolized in the liver, with excretion in feces and urine ¨ Cross the placenta and enter breast milk ¨ NURSING CONSIDERATION: • Administer drug on an EMPTY STOMACH, 1 hour before or 2 hours after meals; may be with meals if GI upset is a problem 4 12/3/18 Contraindications and Cautions Adverse Effects ¨ ¨ ¨ ¨ Pregnancy and lactation Caution with renal and hepatic impairment Special care should be taken when these drugs are used by any patient with a history of arrhythmias or prolonged QT intervals ¨ Drowsiness and sedation Drying of the respiratory and GI mucous membranes, GI upset and nausea, arrhythmias, dysuria, urinary hesitancy, and skin eruption and itching associated with dryness NURSING CONSIDERATIONS: • Patient may experience dry mouth, which may lead to nausea and anorexia; suggest sugarless candies or lozenges. • Increase humidity and push fluids. • Have the patient void before each dose • Provide skin care as needed. NURSING CONSIDERATION: • Assessment Other Nursing Considerations ¨ ¨ Note that patient may have poor response to one of these agents but a very effective response to another; the prescriber may need to try several different agents to find the one that is most effective NURSING CONSIDERATION: • Provide safety measures as appropriate if CNS effects occur • Caution the patient to avoid alcohol while taking these drugs. B. Decongestants ¨ ¨ Caution the patient to avoid excessive dose and to check OTC drugs for the presence of antihistamines. Decrease the overproduction of secretions by causing local vasoconstriction to the upper respiratory tract. Rebound congestion technically called, rhinitis medicamentosa ¤ Reflex reaction to vasoconstriction is a rebound vasodilation, which leads to prolonged overuse of decongestants Nasal Decongestants (sympathomimetic amines) 1. Nasal and Systemic Decongestants ¨ ¨ ¨ ¨ Stimulate the alpha-adrenergic receptors, producing vascular constriction (vasoconstriction) of the capillaries within the nasal mucosa. Shrinking of the nasal mucous membranes and reduction in fluid secretion (runny nose). Nasal Spray or drops or in tablet, capsule, or liquid form. Act promptly and cause fewer side effects 5 12/3/18 Systemic Decongestants Systemic and Nasal Decongestants (alpha-adrenergic agonists) ¨ ¨ Available in tablet, capsule, and liquid form and are used primarily in allergic rhinitis, including hay fever and acute coryza (profuse nasal discharge). Relieve nasal congestion for a longer period than nasal decocngestants; however, currently there are long-acting decongestants. Side Effects and Adverse Effects ¨ ¨ ¨ Jittery, nervous or restless (may decrease or disappear as the body adjusts to the drug) Use of nasal decongestants for as little as 3 days could result to rebound nasal congestion. Blood pressure and blood glucose level can increase NURSING CONSIDERATION: • ¨ ¨ ¨ ephedrine HCl naphazoline HCl oxymetazoline HCl ¨ penylephrine psseudoephidrine ¨ tetrahydrozoline ¨ Drug Interactions ¨ ¨ ¨ Contraindicated or used in with extreme caution in patients with hypertension, cardiac disease, hyperthyroidism, and diabetes mellitus. Pseudoephedrine – decrease the effect of beta blockers Taken together with MAOI’s (monoamine oxidase inhibitors), decongestants may increase the possibility of hypertension or cardiac dysrhythmias. Avoid large amounts of caffeine – it can cause increase restlessness and palpitations. Intranasal Glucocorticoids or steroids 2. Intranasal Glucocorticoids ¨ ¨ ¨ ¨ ¨ ¨ Effective for treating allergic rhinitis. Anti-inflammatory actions May be used alone or in combination with an H1 antihistamine. Continuous use, dryness of the nasal mucosa may occur. Should not be used for longer than 30 days. Most allergic rhinitis is seasonal; therefore the drugs are for short term use unless otherwise indicated by the health care provider. 6 12/3/18 Intranasal Glucocorticoids ¨ ¨ ¨ Beclomethasone Budesonide Dexamethasone ¨ Flunisolide Fluticasone ¨ Triamcinolone ¨ ¨ ¨ Drug Names Therapeutic Actions and Indications ¨ C. Antitussives Dextromethorphan, Codeine, Hydrocodone (Hycodan) Pharmacokinetics ¨ ¤ Act directly on the medullary cough center of the brain to depress the cough reflex ¨ Drugs that suppress the cough reflex Common cold, sinusitis, pharyngitis, and pneumonia, are accompanied by an uncomfortable, unproductive cough Rapidly absorbed and metabolized in the liver, and excreted in the urine. They cross the placenta and enter the breast milk NURSING CONSIDERATION: This drugs should not be used during pregnancy and lactation Benzonatate (Tessalon) ¤ Acts as a local anesthetic on the respiratory passages, lungs, and pleurae, blocking the effectiveness of the stretch receptors that stimulate the cough reflex Contraindications and Cautions ¨ ¨ Contraindicated to patients who need to cough to maintain the airway (e.g. postoperative patients and those who have undergone abdominal and thoracic surgery) Careful use for patients with asthma and NURSING CONSIDERATIONS: emphysema • Assessment • Ensure that the drug is not taken any longer than recommended. • Arrange for further medical evaluation for coughs that persist or are accompanied by high fever, rash, or excessive secretions ¨ ¨ Caution should also be used in patients who are hypertensive to or have history of addiction to narcotics (codeine and hydrocodone) Patients who need to drive or to be alert should use codeine, hydrocodone, and dextromethorphan with extreme caution 7 12/3/18 Adverse Effects ¨ Drug-Drug Interactions Drying effect on the mucus membranes and can increase the viscosity of respiratory tract secretions. ¤ Can ¨ lead to nausea, constipation, dry mouth ¤ hypotension, ¨ CNS depression, drowsiness and sedation GI upset, headache, feelings of congestion, and sometimes dizziness D. Expectorants ¨ ¨ ¨ ¨ Increase productive cough to clear the airways. They liquefy lower respiratory tract secretions, reducing viscosity of these secretions and making it easier for the patient to cough them up. Available in OTC preparations guaifenesin (Mucinex, Robitussin) Pharmacokinetics ¨ ¨ fever, nausea, myoclonic jerks, and coma could occur NURSING CONSIDERATION: • Provide other measures to help relieve cough (e.g. humidity, cool temperatures, fluids, use of topical lozenges) ¨ Dextromethorphan should not be used with monoamine oxidase (MAO) inhibitors Rapidly absorbed with an onset of 30 minutes and a duration of 4 to 6 hours Sites of metabolism and excretion have not been reported. Therapeutic Actions and Indications ¨ ¨ Enhances the output of respiratory tract fluids by reducing the adhesiveness and surface tension of these fluids, allowing easier movement of the less viscous secretions. The result of this thinning of secretions is a more productive cough and thus decreased frequency of coughing. Contraindications ¨ ¨ ¨ The drug should not be used in patients with a known allergy to the drug. Pregnancy and lactation Persistent coughs 8 12/3/18 Adverse Effects ¨ GI symptoms: nausea, vomiting, anorexia NURSING CONSIDERATION: • Advise the patient to take small, frequent meals ¨ E. Mucolytics ¨ Headache, dizziness, or both; occasionally a mild NURSING CONSIDERATION: rash develops • Advise the patient to avoid driving or performing dangerous tasks if dizziness and drowsiness occur ¨ Discover the cause of the underlying cough. ¨ ¨ Not be used more than 1 week ¨ NURSING CONSIDERATION: • Caution the patient not to use these drugs for longer than 1 week and to seek medical attention if the cough persists after that time. • Alert the patient that these drugs may be found in OTC preparations and that care should be taken Therapeutic Actions and Indications ¨ the mucoproteins in the respiratory secretions by splitting apart the bisulfide bonds that are responsible for holding the mucus material together. Pharmacokinetics dornase alfa (Pulmozyme) by recombinant DNA techniques that selectively break down respiratory tract mucous by separating extracellular DNA from proteins. ¨ ¨ ¤ Prepared Contraindication and Cautions ¨ ¨ acetylcysteine (Mucomyst) dornase alfa (Pulmozyme) acetylcysteine (Mucomyst) ¤ Affects ¨ ¨ Increase or liquefy respiratory secretions to aid the clearing of the airways in high-risk respiratory patients who are coughing up thick, tenacious secretions. COPD, cystic fibrosis, pneumonia, or tuberculosis Caution should be used in cases of acute bronchospasm, peptic ulcer, and esophageal varices. There are no data on the effects of drugs in pregnancy and lactation ¨ Administered by nebulization or by direct installation into the trachea via endotracheal tube of tracheostomy. Acetylcysteine is metabolized in the liver and excreted somewhat in urine. Dornase alfa has long duration of action, and its fate in body is not known. Adverse Effects ¨ GI upset, stomatitis, rhinorrhea, bronchospasm, and occasionally a rash. 9 12/3/18 Nursing Considerations ¨ ¨ ¨ ¨ ¨ Assessment Avoid combining with other drugs in the nebulizer. Dilute concentrate with sterile water for injection Note that patients receiving acetylcysteine by face mask should have the residue wiped off the facemask and off their face with plain water . ¨ ¨ ¨ Review use of he nebulizer with patients receiving dornase alfa at home. Patients should be cautioned to store the drug in the refrigerator, protected from light. Caution cystic fibrosis patients receiving dornase alfa about the need to continue all therapies for all their cystic fibrosis Provide thorough patient teaching, including the drug name and prescribed dosage, measures to help avoid adverse effects, warning sings, that may indicate problems, and the need for periodic monitoring and evaluation. Offer support and encouragement. 1. Atelectasis Lower Respiratory Tract Conditions ¨ ¨ ¨ ¨ 2. Pneumonia ¨ ¨ Inflammation of the lungs caused either by bacterial or viral invasion of the tissue or by aspiration of foreign substances into the lower respiratory tract. DOB and fatigue, fever, noisy breath sounds, and poor oxygenation Collapse of once-expanded alveoli Most commonly occurs as a result of airway blockage, which prevents air from entering the alveoli, keeping the lung expanded. Crackles, dyspnea, fever, cough, hypoxia, and changes in chest wall movement Treatment: clearing the airways, delivering oxygen, and assisting ventilation 3. Bronchitis ¨ ¨ ¨ Occurs when bacteria, viruses, or foreign materials infect the inner layer of the bronchi. Swelling, increased blood flow in that area, and changes in capillary permeability Narrowed airway during inflammation 10 12/3/18 4. Bronchiectasis ¨ ¨ ¨ ¨ Chronic disease that involves the bronchi and bronchioles. Dilation of the bronchial tree and chronic infection and inflammation of the bronchial passages 5. Obstructive Pulmonary Disease ¨ ¤ Reversible bronchospasm, inflammation, and hyperactive airways ¤ Allergens or nonellergic inhaled irritants or by factors such as exercise and emotion. Fever, malaise, myalgia, arthralgia, and a purulent, productive cough Chronic Obstructive Pulmonary Disease (COPD) ¤ Trigger causes an immediate release of histamine, which results in bronchospasm in about 10 minutes. The later response (3 to 5 hours) is cytokine-mediated inflammation, mucus production, and edema contributing to obstruction. ¨ Cystic fibrosis ¤ Hereditary disease involving the exocrine glands of the respiratory, gastrointestinal, and reproductive tracts ¤ Results in accumulation of copious amounts of very thick secretions in the lungs ¤ Permanent chronic obstruction of airways, often related to cigarette smoking loss of elastic tissue of the lungs, destruction of alveolar walls, and a resultant alveolar hyperinflation with a tendency to collapse with expiration Asthma ¤ Emphysema: ¨ Respiratory Distress Syndrome (RDS) ¤ Causes obstruction at the alveolar level seen in infants who are delivered before their lungs have fully developed and while surfactant levels are still very low. ¤ Treatment: instilling surfactant to prevent atelectasis and to allow lungs to expand ¤ Frequently ¤ Chronic bronchitis: permanent inflammation of the airways with mucus secretion, edema, and poor inflammatory defenses. A. Bronchodilators/Antiasthmatics Drugs acting on the LOWER respiratory tract ¨ ¨ ¨ ¨ Medications used to facilitate respirations by dilating the airways. Asthma and COPD Administered orally and absorbed systemically Other medications are administered directly into the airways by nebulizers ¤ Sympathomimetics ¤ Anticholinergics ¤ Xanthines 11 12/3/18 1. Sympathomimetics ¨ ¨ ¨ ¨ ¨ ¨ ¨ Drugs that mimic the effects of the sympathetic nervous system (dilation of the bronchi with increased rate and depth of respiration). albuterol (Proventil) arformoterol (Brovana) bitolterol (Tornalate) ephedrine (generic) epinephrine (EpiPen) terbutaline (Brethaire) Contraindications and Cautions ¨ Therapeutic Actions and Indication Contraindicated and should be used with caution, depending on the severity of the underlying condition: ¨ ¨ ẞ-2 receptors found in the bronchi Effects of higher levels of sympathomimetics ¤ ¨ Increased BP, increased HR, vasoconstriction, and decreased renal and GI blood flow Epinephrine ¤ Drug of choice for the treatment of acute bronchospasm, including that caused by anaphylaxis Adverse Effects ¨ CNS stimulation, GI upset, cardiac arrhythmias, hypertension, bronchospasm, sweating, pallor, and flushing. ¤ Cardiac disease, vascular disease, arrhythmias, diabetes, and hyperthyroidism ¨ Can be used during pregnancy and lactation ONLY if the benefits to the mother clearly outweigh potential risks to the fetus or neonate. Drug-Drug Interactions ¨ Avoid combination of sympathomimetic bronchodilators with general anesthetics cyclopropane and halogenated hydrocarbons. Nursing Considerations ¨ ¨ Assessment Reassure patient that the drug of choice will vary with each individual. ¨ Advise the patient to use the minimal amount needed for the shortest period necessary. Teach patients who use one of these drugs for exercise-induced asthma to use it 30 to 60 minutes before exercising. ¨ Provide safety measures as needed. ¨ 12 12/3/18 2. Anticholinergics ¨ ¨ ¨ Provide small, frequent meals and nutritional consultation if GI effects interfere with eating Provide thorough patient teaching, including the drug name and prescribed dosage, measures to help avoid adverse effects, warning signs that may indicate problems, and the need for periodic monitoring and evaluation. Offer support and encouragement. Therapeutic Actions and Indications ¨ Used as bronchodilators because of their effect on the vagus nerve (to block or antagonize the action of the neurotransmitter acetylcholine at vagal-mediated receptor sites) Contraindications and Cautions ¨ ¨ Narrow-angle glaucoma, bladder neck obstruction or prostatic hypertrophy, and conditions aggravated by dry mouth or throat. ¨ ¨ ¨ ipratropium (Atrovent) tiotropium (Spiriva) These drugs are not as effective as the sympathomimetics but can provide some relief to those patients who cannot tolerate the other drugs Pharmacokinetics ¨ ¨ Available in inhalation, using an inhaler device. Ipratropium is also available as a nasal spray for seasonal rhinitis. ¤ Onset ¤ Peak of action – 15 minutes when inhaled – 1 to 2 hours ¤ Duration – 3 to 4 hours Adverse Effects ¨ Dizziness, headache, fatigue, nervousness, dry mouth, sore throat, palpitations, and urinary retention Presence of known allergy to the drug or to soy products or peanuts. ¨ Pregnancy and lactation 13 12/3/18 Nursing Considerations ¨ ¨ ¨ ¨ ¨ Ensure adequate hydration and provide environmental controls, such as the use of a humidifier. Encourage patient to void before each dose of medication. Provide safety measures if CNS effects occur. Provide small, frequent meals and sugarless lozenges. Advise the patient not to drive or use hazardous machinery if nervousness, dizziness, and drowsiness occur with this drug treatment. 3. Xanthines ¨ ¨ ¨ ¨ ¨ ¨ ¤ aminophylline ¨ ¤ caffeine (Caffedrine) ¤ dyphylline (Dilor) ¤ theophylline (Slo-Bid, Theo-Dur) Review the use of the inhalator with the patient; caution the patient not to exceed 12 inhalations in 24 hours. Offer support and encouragement. Therapeutic Actions and Indications Including caffeine and theophylline, come from a variety of naturally occurring sources. Xanthines used to treat respiratory disease include: (Truphylline) Provide thorough patient teaching, including the drug name and prescribed dosage, measures to help avoid adverse effects, warning signs that may indicate problems, and the need for periodic monitoring and evaluation. ¨ Have direct effect on smooth muscles of the respiratory tract, both the bronchi and in the blood vessels. Inhibit the release of slow-reacting substance of anaphylaxis (SRSA) and histamine, decreasing the bronchial swelling and narrowing. Unlabeled use: ¤ ¤ Pharmacokinetics ¨ ¨ ¨ ¨ Oral: Rapidly absorbed in the GI tract, reaching peak levels within 2 hours. IV: peak effects within minutes Both are widely distributed and metabolized in the liver and excreted in the urine. They cross the placenta and enter breast milk Stimulation of respirations in Cheyne-Stokes respiration Treatment of apnea and bradycardia in premature infants Contraindications and Cautions ¨ ¨ ¨ Caution should be taken with any patient with GI problems, coronary disease, respiratory dysfunction, renal and hepatic disease, alcoholism, or hyperthyroidism Parenteral drug should be switched to the oral form ASAP. Pregnancy and lactation 14 12/3/18 Adverse Effects ¨ Drug-Drug Interactions Theophylline levels in the blood (N = 10 to 20 mcg/ml) n GI upset, nausea, irritability, and tachycardia to seizures, brain damage, and even death Serum Level (mcg/ml) ≥20 Adverse Effects ¨ ¨ ¨ ¨ >20-25 Nausea, vomiting, diarrhea, insomnia, headache, irritability >30-35 Hyperglycemia, hypotension, cardiac arrhythmias, tachycardia, seizures, brain damage, death Administer drug with food or milk. Monitor patient response to the drug (e.g. relief, of respiratory difficulty, improved airflow). Provide comfort measures, including rest periods, quiet environment, dietary control of caffeine, and headache therapy as needed. Provide periodic follow-up, including blood tests. Provide thorough patient teaching, including drug name and prescribed dosage, measures to help avoid adverse effects, warning signs that may indicate problems, and the need for periodic monitoring and evaluation. 1. Leukotriene Receptor Antagonist ¨ ¨ ¨ ¨ Developed to act more specifically at the site of the problem. zafirlukast (Accolate) – first drug of this class to be developed montelukast (Singulair) zileuton (Zyflo) ¨ Uncommon Nursing Considerations ¨ ¨ Nicotene increases the metabolism of xanthines in the liver; xanthine dose must be increased in patients who continue to smoke while using xanthines. Extreme caution must be used if the patient decides to decrease or discontinue smoking, because severe xanthine toxicity can occur. B. Drugs Affecting Inflammation ¨ ¨ ¨ ¨ To alter the inflammatory process that leads to swelling and further airway narrowing Leukotriene receptors Inhaled steroids Mast cell stabilizer Therapeutic Actions and Indications ¨ Block many of the signs and symptoms of asthma, such as: ¤ Neutrophil and eosinophil migration, Neutrophil and monocyte aggregation, Leukocyte adhesion, Increased capillary permeability, and Smooth muscle contraction ¤ These are the factors that contribute to the inflammation, edema, mucus secretion, and bronchoconstriction 15 12/3/18 Pharmacokinetics ¨ ¨ ¨ Given orally Rapidly absorbed in the GI tract Metabolized in the liver ¨ Cross the placenta and enter breast milk zafirlukast, montelukast – excreted in feces ¨ Zileuton – cleared through the liver ¨ Adverse Effects ¨ Headache, dizziness, myalgia, nausea, diarrhea, abdominal pain, elevated liver enzyme concentrations, vomiting, generalized pain, and fever. Contraindications and Cautions ¨ ¨ ¨ ¨ Should be given cautiously in patients with hepatic or renal impairment Should be used in pregnancy only it the benefit to the mother outweighs the potential risks to the fetus. Caution should be used during lactation Not indicated for the treatment of acute asthmatic attacks Drug-Drug Interactions ¨ ¨ Use caution if propanolol, theophylline, terfenadine, or warfarin is taken with these drugs because increased toxicity can occur. Combined with calcium channel blockers, cyclosporine, or aspirin. Nursing Considerations ¨ ¨ ¨ ¨ Administer drug in an empty stomach, 1 hour before or 2 hours after meals. Caution the patient that these drugs are not to be used during an acute asthmatic attack or bronchospasm. Caution the patient to take the drug continuously and not to stop the medication during symptomfree periods. Provide adequate safety measures if dizziness occurs. ¨ Urge the patient to avoid OTC preparations containing aspirin Provide patient thorough teaching. ¨ Offer support and encouragement. ¨ 16 12/3/18 2. Inhaled Steroids ¨ ¨ Found to be very effective treatment of bronchospasm beclomethasone (Beclovent) ¨ budesonide (Pulmicort) ciclesonide (Alvesco) flucticasone (Flovent) ¨ triamcinolone (Azmacort) ¨ ¨ Pharmacokinetics ¨ Rapidly absorbed from the respiratory tract, but they take 2 to 3 weeks to reach effective levels. Metabolized in the liver and excreted in the urine. ¨ Crosses the placenta and enters the breast milk ¨ Adverse Effects ¨ Sore throat, hoarseness, coughing, dry mouth, and pharyngeal and laryngeal fungal infections Therapeutic Actions and Indications ¨ Used to decrease inflammatory response in the airway. Increases air flow and facilitate respiration ¨ Two effects: ¨ ¤ Decreased ¤ Promotion swelling associate with inflammation of beta-adrenergic receptor activity Contraindications and Cautions ¨ ¨ ¨ Not for emergency use and not for use during an acute asthma attack or status asthmaticus Pregnancy and lactation Caution in any patient who has an active infection of the respiratory system. Nursing Considerations ¨ Assessment ¤ Acute asthmatic attacks and allergy to the drugs; systemic infections, pregnancy and lactation ¤ Perform physical examination ¤ Assess temperature ¤ Monitor BP, pulse, and auscultation ¤ Assess respirations and adventitious sounds ¤ Examine the nares 17 12/3/18 Implementation ¨ ¨ ¨ ¨ ¨ Do not administer the drug to treat an acute asthma attack or status asthmaticus. Taper systemic steroids carefully during the transfer to inhaled steroids. Have the patient use decongestant drops before using the inhaled steroid. Have the patient rinse the mouth after using the inhaler. Monitor the patient for any sign of respiratory infection. 3. Mast Cell Stabilizer ¨ ¨ Prevents the release of inflammatory and bronchoconstricting substances when the mast cells are stimulated to release these substances because irritation or the presence of an antigen. cromolyn (Nasalcrom) – the only drug still available in this class. ¨ ¨ ¨ ¨ ¨ ¨ Inhaled from a capsule and may not reach its peak effect for 1 week. Available as a nasal spray and as an ophthalmic solution (little systemic absorption) Active in the lungs and most of the inhaled dose is excreted during exhalation, or if swallowed, excreted in urine and feces. Instruct the patient to continue to take the drug. Offer support and encouragement. Therapeutic Actions and Indications ¨ ¨ ¨ ¨ Pharmacokinetics Provide thorough patient teaching, including the drug name and prescribed dosage, measures to help avoid adverse effects, warning signs that may indicate problems and the need for periodic monitoring and evaluation. Treatment of asthma and allergies Works at the cellular level to inhibit the release of histamine and inhibits the release of SRSA. Prevents the allergic asthmatic response when respiratory tract is exposed to the offending allergen. Seasonal allergic rhinitis and in an inhaled form for the treatment of allergies. Contraindications and Cautions ¨ ¨ ¨ ¨ Allergy to the drug Cannot be used in acute attack and patients need to be instructed in this precaution. Pregnancy and lactation (reserved for those situations when the benefit to the mother outweighs any potential risk to the fetus and neonate) Not recommended for children younger than 2 years of age. 18 12/3/18 Adverse Effects ¨ ¨ Swollen eyes, headache, dry mucosa, and nausea Careful patient management can help to make drug-related discomfort tolerable. ¤ avoid dry and smoky environments, analgesics, use of proper inhalation technique, use of a humidifier, and pushing fluids as appropriate Nursing Considerations ¨ ¨ ¨ ¨ ¨ ¨ ¨ C. Lung Surfactants ¨ Allows expansion of the alveoli for gas exchange. beractant (Survanta) calfactant (Infasurf) ¨ poractant (Curosurf) - newest ¨ ¨ Pharmacokinetics ¨ ¨ ¨ Directly instilled in the trachea and begin to act immediately on instillation. Metabolized in the lungs by normal surfactant metabolic pathways. NO CONTRAINDICATIONS Review administration with the patient periodically. Caution the patient not to discontinue use abruptly. Instruct the patient taking cromolyn that this drug cannot be used during an acute attack. Caution the patient to continue taking this drug, even during symptom-free periods. Advise patient not to wear soft contact lenses; if cromolyn eye drops are used. Provide thorough patient teaching. Offer support and encouragement. Therapeutic Actions and Indications ¨ Used to replace the surfactant that is missing in the lungs of neonates with RDS Adverse Effects ¨ ¨ Patent ductus arteriosus, braducardia, hypotension, intraventricular hemorrhage, pnuemothorax, pulmonary air leak, hyperbilirubinemia, and sepsis. These effects may be related to the immaturity of the patient, the invasive procedures used, or reactions to the lipoprotein. 19 12/3/18 Nursing Considerations ¨ ¨ ¨ ¨ ¨ ¨ Monitor the patient continuously during administration and until stable Ensure proper placement of the endotracheal tube with bilateral chest movement and lung sounds. Have staff view the manufacturer’s teaching video before regular use. Suction infant immediately before administration, but do not suction for 2 hours after administration unless clinically necessary. Provide support and encouragement to parents of the patient, explaining the use of the drug in the teaching program. Continue supportive measures related to the immaturity of the infant. 20