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Respiratory drugs

Respiratory Drugs
Mycobacterium (MTB)
• Common infection sites
Lung (primary site)
Brain (cerebral cortex)
Bone (growing end)
Genitourinary tract
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Mycobacterium (MTB)
Infections (Cont.)
• Tubercle bacilli are conveyed by droplets.
• Droplets are expelled by coughing or sneezing, and
they then gain entry into the body by inhalation.
• Tubercle bacilli then spread to other body organs via
blood and lymphatic systems.
• Tubercle bacilli may become dormant, or walled off by
calcified or fibrous tissue.
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Mycobacterium (MTB)
Infections (Cont.)
• MTB: very slow-growing organism
• More difficult to treat than most other bacterial
• First infectious episode: primary TB infection
• Reinfection: chronic form of the disease
• Dormancy: may test positive for exposure but are not
necessarily infectious because of this dormancy
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How is TB Diagnosed?
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Normal Chest XRay
Chest X-ray Tuberculosis
PPD Test
Test must be read 48-72 hours after placement
Anti - Tuberculosis Agents
(Ch. 90)
• Tuberculosis
Latent TB
A person with latent TB infection:
•Usually has a PPD skin test or blood test result indicating TB infection
•Has a normal chest x-ray and a negative sputum test
•Has TB bacteria in his/her body that are alive, but inactive
•Does not feel sick
•Cannot spread TB bacteria to others
•Needs treatment for latent TB infection to prevent TB disease; however, if exposed
and infected by a person with multidrug-resistant TB (MDR TB) or extensively drugresistant TB (XDR TB), preventive treatment may not be an option
Active TB
A person with TB disease:
•Skin test (Mantoux) or blood test result indicate TB infection
•Abnormal chest x-ray, or positive sputum smear or culture
•Has active TB bacteria in his/her body
•Usually feels sick and may have symptoms such as coughing, fever, and weight loss
•May spread TB bacteria to others
•Needs medications to treat TB disease
Active TB Symptoms
Active TB Symptoms
Weight loss/anorexia
Night sweats
Chest pain
Antitubercular Drugs
• First-line drugs:
INH: primary drug used
pyrazinamide (PZA)
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Antitubercular Drugs
• Second-line drugs:
para-aminosalicyclic acid (PAS)
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A patient with TB has been taking antitubercular
drugs. A sputum culture is ordered to test for
acid-fast bacilli. When is the best time for the
nurse to obtain the sputum culture?
5 PM
10 PM
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Isoniazid (INH)
• INH: primary agent for treatment
& prophylaxis of TB
• Action:
– Suppresses bacterial growth by inhibiting
synthesis of mycolic acid, a component of the
mycobacterial cell wall.
– Metabolized in the liver through acetylation—
watch for “slow acetylators”
• Contraindicated with liver disease
Isoniazid (INH)
• Use:
– Active TB
– Latent TB
• Adverse Effects
– Hepatotoxicity
– Peripheral neuropathy
• Administer pyridoxine (Vitamin B6) daily in high risk
groups (i.e., DM, ETOH abuse) or if patient develops
Isoniazid (INH)
• INH requires a certain enzyme pathway to break
down the drug. Called acetylation.
– Some people have a genetic deficiency of the enzyme.
They are slow acetylators. May need to adjust the dose of
INH downward in these patients.
– About 50% of Americans are slow acetylators and 50% fast.
Avg. plasma level is 30-50 times higher in slow acetylators.
• Fast acetylators may need more drug.
• Slow acetylators - higher risk for some side effects.
Drug Interactions: INH
Interacting Drug
Carbamazepine (Tegretol)
*May inc. incidence of INH
induced hepatitis & seizures
*may inc. anticoagulant activity –
result in serious bleeding
*Inc. toxicity of benzo.’s
*inc. risk of carbamazepine
*Inc. hazard of CNS toxicity
*Inc. risk of phenytoin toxicity
A patient with a diagnosis of TB will be taking INH as part of the
anti-TB therapy. When reviewing the patient’s chart, the nurse
finds documentation that the patient is a “slow acetylator.” This
means that:
A. the dosage of INH may need to be lower to prevent INH
B. the dosage of INH may need to be higher because of the
slow acetylation process.
C. he should not take INH.
D. he will need to take a combination of anti-TB drugs for
successful therapy.
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Rifampin (RIF)
• Broad spectrum antibiotic; active against:
Gram positive bacteria
Many gram negative bacteria
M. tuberculosis
M. leprae
Neisseria meningitis
– meningococcal carrier state
• MOA: inhibits bacterial DNA-dependent RNA
polymerase -> results in suppression of RN
synthesis and protein synthesis
– Selectively toxic to microbes
• Absorption:
– Better absorbed if taken on an empty stomach
– Teach patient to take 1 hour before or 2 hours after a
• Elimination:
– Via liver -> induces hepatic drug-metabolizing enzymes;
results in drug being metabolized more over the first week
of therapy -> dec. in half life
• Drug interactions
– Accelerated metabolism of other drugs
• Induces the P450 cytochrome enzymes
– Oral contraceptives, warfarin, protease inhibitors (TX for HIV)
» Teach women to use non hormonal form of birth control
• Adverse effects:
– Hepatotoxicity
• Can develop clinical hepatitis (jaundice, anorexia,
malaise, fatigue, nausea, darkened urine, pale stools)
• Those at risk include ETOH abusers, pre-existing liver
• Monitor LFTs (ALT, AST) baseline, then every 2 to 4
– Discoloration of body fluids
• Red-orange color to urine, sweat, saliva, tears
Analogs of Rifampin
• Rifapentine
– Long acting analog of rifampin.
– Adverse events – same as rifampin
• Rifabutin
– Close chemical relative of rifampin
– Adverse events – rash, GI disturbances, redorange color of body fluids, uveitis
– Drug-drug interactions like rifampin
Pyrazinamide (PZA)
• Bactericidal; mechanism of action unknown
• Used in combination w/ other antituberculosis
• Adverse effects:
– Hepatotoxicity
• Monitor ALT & AST (liver function tests) at baseline and every 2-4
– Non-gouty polyarthralgias – (pain in multiple joints) occurs
in 40% of patients
– Usually responds to NSAIDS
Ethambutol (ETH)
• Active only against M. tuberculosis
– Active against TB stains that are resistant to INH & rifampin
• Bacteriostatic
• Used in combination w/ other antituberculosis
• Adverse effects:
– Optic neuritis – blurred vision, constriction of visual
fields, & disturbance of color discrimination (red-green
color blindness).
– Teach to report immediately; do not use in children < 8 yo
Putting it all Together
• Treatment of Tuberculosis
– Latent TB
– Active TB
Direct Observation Treatment
Nursing Implications
• Obtain a thorough medical history and assessment.
• Perform liver function studies in patients
who are to receive INH or rifampin
(especially in older patients and those who use
alcohol daily).
• Assess for contraindications to the various drugs,
conditions for cautious use, and potential drug
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Nursing Implications
• Patient education is critical.
• Therapy may last for up to 24 months.
• Take medications exactly as ordered at the same time
every day.
• Emphasize the importance of strict adherence to
regimen for improvement of condition or cure.
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Patient Teaching
• Educate the patient about the importance of
strict adherence to the drug regimen for
improvement or cure of the condition.
• Provide instructions in written and oral formats
about drug interactions and need to avoid
alcohol while taking any of these medications.
A nursing student is at the clinic to be screened for
tuberculosis. The nurse performs a purified protein
derivative (PPD) test on the right forearm today.
When should the student return to have the test
A. One hour after the test is placed
B. 24 hours after performing the test
C. 48 hours after performing the test.
D. 5-7 days after performing the test
A patient is receiving INH for the treatment of TB.
Which vitamin does the nurse anticipate
administering with the INH to prevent INHprecipitated peripheral neuropathies?
Vitamin C
Vitamin B12
Vitamin D
Vitamin B6
A 30-year-old female patient whose
father was diagnosed with active TB. Her
provider recommended a prophylactic
antibiotic for 6 months. She was placed
on rifampin (Rifadin).
She calls the office today and is quite
anxious because her urine was bright
orange when she voided this morning.
What is making her urine orange? Should
she be concerned?
Mary read that antibiotics may cause
birth control pills to be ineffective, and
she asks the nurse if this is the case with
Should Mary be concerned about the
effectiveness of her birth control pills?
B. No
Drugs for Allergic Rhinitis
Intranasal steroids
Intranasal Cromolyn
Sympathomimetics (Decongestants)
Intranasal Glucocorticoids
• Most effective drugs for prevention / treatment
of seasonal & perennial rhinitis
– 90% of patients respond well
• MOA: decrease inflammation & edema
• Word ending for steroids: “sone”
• Adverse events:
– Systemic effects rare
– Local reactions: drying of nasal mucosa; burning or
itching sensation; sore throat, epistaxis, headache
Intranasal Glucocorticoids
• Administered via a metered-dose spray
– May take up to 2-3 weeks for benefit
Administration Tips
• Aim to deliver the dose throughout the lining of the
nasal cavity.
• Have patient tilt head forward, directing the nozzle
slightly away from the midline to avoid contact with
the septum.
• Do not blow nose for at least one minute post
(Ch. 70)
• Uses:
– Relief of symptoms of mild to moderate allergic
disorders including allergic rhinitis, allergic
conjunctivitis, uncomplicated urticaria, & angioedema
• Contraindicated in 3rd trimester of pregnancy,
nursing mothers, newborn infants
– Exercise caution when using in small children; consult physician
– Exercise caution when using in the elderly
– Exercise caution in patients with asthma, urinary retention, openangle glaucoma, hypertension, & benign prostatic hypertrophy
Allergic Rhinitis
1st Generation Antihistamines
Things to Know
chlorpheniramine (Chlor-Trimeton)
Diphenhydramine (Benadryl)
Causes drowsiness
Promethazine (Phenergan)
Contraindicated in children < 2 yo; can
cause severe respiratory depression
Do not give IV – can cause serious local
tissue damage
Also used as an anti-emetic
Adverse Effects: H1 Antihistamines
First Generation Antihistamines
Nursing Implications
• 1st generation antihistamines – take at
bedtime to avoid sedation
– If taken during day, caution the patient about
safety measures w/ driving, operating machinery,
& ambulating. Sedation usually decreased w/
repeated doses.
2nd Generation Antihistamines
Fexofenadine (Allegra)
Cetirizine (Zyrtec)
Loratadine (Claritin)
Desloratadine (Clarinex)
Poorly cross the blood-brain barrier
Have a low affinity for H1 receptors in the CNS
Because of these characteristics – do not cause the sedation seen in
the first generation antihistamines
Phenylephrine (Neo-synephrine)
Pseudoephrine (Sudafed)
Oxymetazoline (Afrin)
• MOA: activate alpha1 adrenergic receptors on nasal
blood vessels -> vasoconstriction
– Decongestants reduce nasal congestion.
• Adverse effects
– Rebound congestion (topicals) used for more than 5 days
– CNS stimulation (oral) – restlessness, anxiety, insomnia
– CV effects (oral) – tachycardia, inc. BP
• Use cautiously HTN, dysrhythmias, cerebrovascular disease
– Abuse – pseudoephedrine used to make methamphetamines
Nursing Implications
• Instruct patient not to overuse the agent
because maybe habit-forming w/ episodes of
rebound engorgement. Limit number of days
med used.
• Have patient limit caffeine intake
• Take early in day – insomnia
Advise patient to take in sitting position when
When assessing a patient who is to receive a
decongestant, the nurse will recognize that a
potential contraindication to this drug would be
which condition?
a. Glaucoma
b. Fever
c. Peptic ulcer disease
d. Allergic rhinitis
Medications used to Manage
Allergy and Asthma Medications
Evaluating Therapeutic Effect
• Patient needs to monitor and record Peak
Expiratory Flow (PEF)
• Should measure every A.M.
• If reading <80% of their best, monitor
Quick Relief
• Short-acting inhaled beta2 agonists (rescue agents)
• IV {systemic corticosteroids} (less quickly)
Long-Term Control
Leukotriene receptor antagonists
Mast cell stabilizers
Inhaled corticosteroids
Anticholinergic agents
Long-acting beta2 agonists (LABA)
Long-acting beta2 agonists in combination with inhaled
Pharmacologic Overview
• Bronchodilators
– These drugs relax bronchial smooth muscle, which causes
dilation of the bronchi and bronchioles that are narrowed
as a result of the disease process.
– Three classes: beta-adrenergic agonists, anticholinergics,
and xanthine derivatives
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Classes of Bronchodilators
• Sympathomimetic Agents (beta2 agonist)
(Asthma & COPD)
• Xanthine bronchodilators (Asthma & COPD)
• Anticholinergics (COPD)
Bronchodilators: Beta-Adrenergic
• Short-acting beta agonist (SABA) inhalers
albuterol (Ventolin)
levalbuterol (Xopenex)
pirbuterol (Maxair)
terbutaline (Brethine)
metaproterenol (Alupent)
• Long-acting beta agonist (LABA) inhalers
– arformoterol (Brovana)
– formoterol (Foradil, Perforomist)
– salmeterol (Serevent)
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Selective Beta2 Receptor Drugs
(Beta2-adrenergic agonists)
• SABA (short acting beta2 agonist)
• LABA (long acting beta2 agonist)
• Mechanism of action (asthma): activate beta2 receptors in
smooth muscle of lung to promote muscle relaxation,
bronchodilation, relieve bronchospasms, and increase airflow
– Also suppresses release of histamine
– Increases ciliary motility
• SABA used during the acute phase of asthma attacks (rescue)
– Quickly reduces airway constriction and restores normal
Commonly Used Drugs
• Common drugs
• Albuterol (Proventil, Ventolin)
• Levalbuterol (Xopenex)
• formoterol and budesonide (Symbicort)
• formoterol and mometasone (Dulera)
• salmeterol and fluticasone( Advair)
Beta-Adrenergic Agonists: Indications
• Relief of bronchospasm related to asthma,
bronchitis, and other pulmonary diseases
• Used in treatment and prevention of acute attacks
• Used in hypotension and shock
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Beta-Adrenergic Agonists:
Albuterol (Proventil)
• Short-acting beta2-specific bronchodilating beta
• Most commonly used drug in this class
• Used for quick relief of bronchoconstriction
• Oral and inhalational use
• Inhalational dosage forms include metered-dose
inhalers (MDIs) as well as solutions for inhalation.
• Must not be used too frequently
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Beta-Adrenergic Agonists:
Salmeterol (Serevent)
• Long-acting beta2 agonist (LABA) bronchodilator
• Never to be used for acute treatment
• Used for the maintenance treatment of asthma and
COPD and is used in conjunction with an inhaled
• Salmeterol should never be given more than twice
daily nor should the maximum daily dose (one puff
twice daily) be exceeded.
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Beta2 Agonists: Adverse Effects
• CNS: anxiety, restlessness, insomnia, tremors,
• CV: palpitations, dysrhythmias
• Respiratory: rebound bronchospasm
• GU: urinary retention
• GI: nausea, gastroesophageal reflux
• Oral infections
• Caution or contraindicated in patients w/ HTN,
• Increased cardiac effects if patient is taking a
xanthine (theophylline)
• Patient should have inhaler available at all
times to use to reverse an acute attack.
• Recommended to use the inhaler before an
activity that triggers an attack.
Drug Interactions: Albuterol
Interacting Drug
*May increase sympathomimetic
effects & risk of toxicity.
MAO inhibitors
*May cause serious CV reactions,
such as arrhythmias or
Orally inhaled sympathomimetics *May increase sympathomimetic
effects & risk of toxicity.
Tricyclic antidepressants
* May cause serious CV reactions,
such as tachycardia &
Albuterol: Nursing Management
Frequent pulmonary assessment
Smoking cessation
Avoid caffeine - stimulant
After long term use, shorter duration of action (1-2
h); tolerance may stimulate adverse cardiac reactions
if dose continues to be increased.
• Foul taste will gradually disappear
• Rinse mouth after inhalation
Albuterol: Nursing Management
• Excessive use may cause paradoxical
• Do not add drugs to regimen; no OTC
(primatene mist, bronkaid mist)
• Report: chest pain, extreme dizziness, severe
HA, palpitations, tachycardia, HTN
Mechanism of Action
• Acetylcholine (ACh) causes bronchial constriction
and narrowing of the airways.
• Anticholinergics bind to the ACh receptors,
preventing ACh from binding.
• Result: bronchoconstriction is prevented, airways
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Allergy & Anaphylaxis
Know Anaphylaxis Symptoms
Breathing Difficulty
Swelling or hives
Tightness of the throat
Hoarse voice
Abdominal pain
Low blood pressure
Rapid heart beat
Feeling of impending doom
Cardiac arrest
Beta Agonist Bronchodilator
Inhaler Administration
Nebulizer Treatment
Which medication will the nurse teach a
patient with asthma to use when experiencing
an acute asthma attack?
albuterol (Ventolin)
salmeterol (Serevent)
theophylline (Theo-Dur)
montelukast (Singulair)
The patient is prescribed albuterol (Ventolin), a
sympathomimetic bronchodilator, metered-dose
inhaler. Which behavior indicates the teaching
concerning the inhaler is effective?
A. The patient holds his or her breath for 5 seconds
prior to using the inhaler.
B. The patient states it is important to avoid using
the inhaler before exercise.
C. The patient exhales and then squeezes the
inhaler canister as inspiration begins.
D. The patient connects the oxygen tubing to the
inhaler before administering the dose
• Oldest class of bronchodilators; contains caffeine
• MOA: increases levels of energy-producing cAMP
inhibits phosphodiesterase which is an enzyme that breaks
down cAMP
• Results in:
Smooth muscle relaxation
Increased airflow
Can cause cardiac life-threatening side effects
• Most common drug:
– Theophylline (Theo-Dur)-oral form; maintenance of chronic
stable asthma
– IV form is Aminophylline; no more effective than current drugs
• Adverse effects:
– CNS stimulation: tremors (a later sign of toxicity),
nervousness, insomnia, agitation, convulsions
– CV stimulation: tachycardia, tachydysrhythmias,
angina, hypotension, palpitations
– GI distress: nausea (first sign of toxicity), vomiting,
• Toxicity
– Related to theophylline levels. Normal range
10mcg/ml - 20mcg/ml
• Mild Toxicity – n/v, diarrhea, insomnia, restlessness
• Serious (over 30 mcg/ml) – severe dysrhythmias, convulsions
Xanthines: Nursing Care
• Teach patients that taking foods high in caffeine can
increase adverse effects.
• Monitor blood levels for drug toxicity (usually
checked 1-2 times per year)
• Give daytime to prevent insomnia
• Have patient take on full stomach or with milk if have
GI distress
• Avoid smoking – increases metabolism of the drug
• Can interact with many other drugs
Xanthine Derivatives &
Administer cautiously & monitor for sensitivity D/T decreased drug metabolism.
Monitor for adverse effects and toxicity
Instruct to never chew or crush sustained-released dosage forms.
Be aware of drug interactions (especially interactions with other asthma-related
Advise to avoid omitting and/or doubling up on doses
Monitor serum levels to avoid possible toxicity/ ensure therapeutic blood levels.
Lower dosages may be necessary initially in elderly patients (decreased liver &
renal function).
Report palpitations & increased blood pressure
Leukotriene Receptor Antagonists
• Non-bronchodilating
• Newer class of asthma medications
• Currently available drugs
– montelukast (Singulair)
– zafirlukast (Accolate)
– zileuton (Zyflo)
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Leukotriene Receptor Antagonist
• MOA: inhibition of leukotrienes at receptors in the smooth
muscle of airways, which is triggered by inflammatory
• Uses: prophylactic treatment of mild to moderate persistent
asthma or to replace ICS.
• Educate patient
– Use for chronic asthma management; not for acute asthma
– Should see improvement within 1 week
Leukotriene Receptor Antagonist
• Montelukast (Singulair)
• Zafirlukast (Accolate)
• Adverse Effects
– Headache, dizziness, insomnia, suicidality
– Nausea
– Diarrhea
– Liver dysfunction (monitor LFTs)
5-Lipoxygenase Inhibitors
New class of leukotriene receptor antagonists
No direct bronchodilation activity
Indirect acting
Stabilize the cell membranes of the
inflammatory cells - mast cells, monocytes,
– Prevent release of harmful cellular content
Zileuton: the first 5-lipoxygenase inhibitor for the
treatment of asthma
Mast Cell Stabilizers
• Stabilize mast cells, reducing the release of
mast cell chemicals that cause
bronchoconstriction, edema, and
inflammation. Interrupts migration of
eosinophils into site, thus decreases # of
• Commonly cromolyn sodium solution
(Gastrocrom, Intal, Nasalcrom)
• Indicated for the prophylaxis of asthma attacks & is
often used in conjunction with other agents.
– Requires several weeks before effective. It is
prophylactic. Not used as rescue med!
• Used for prophylactic seasonal allergic
asthma, allergic rhinitis, perennial allergic
asthma, animal-induced asthma, exerciseinduced asthma, irritant-induced asthma
• Pharmaceutics - inhalation, aerosol spray,
nasal solution, ophthalmic solution, capsule
• Cromolyn nasal drops (Nasalcrom) prophylaxis or tx.
For allergic rhinnitis.
• Cromolyn ophthalmic solution for ocular allergy
symptoms (Optimcrom)
Cromolyn - Adverse Effects
• Common- transient cough, wheezing, Nausea, bad
taste, dry or irritated throat
• Infrequent S/E- dizziness, vertigo, neuritis, dry
mouth, dysuria, rash, tracheal irritation, nasal
Cromolyn - Contraindications
• Don’t use to treat acute asthma, especially
status asthmaticus
• Administer only in children older than 2 years
of age
• Pregnancy risk category B
Cromolyn - Nursing
• Teach pt. To use metered-dose inhaler correctly.
– Hold breath for 5-10 seconds
• Tell pt. To who use a bronchodilator inhaler to administer a dose 5
min. before taking Cromolyn.
• Be aware that therapeutic effects may not be seen for 2-4 weeks
after therapy starts.
• Monitor pulmonary status before and immediately after therapy.
• Reassure pt. That the nasal solution may cause stinging or sneezing
immediately after the drug is instilled.
• Encourage patient to use the inhaler before brushing the teeth to
reduce oral infections & to wash the mouthpiece with warm water
and dry thoroughly once per week
Inhaled Glucocorticoids
Inhaled Corticosteroids (ICS)
• Work by suppressing inflammation
– Decrease synthesis & release of inflammatory
mediators including leukotrienes, histamine,
– Decrease infiltration & activity of inflammatory
cells including eosinophils, leukocytes
– Decrease edema of the airway mucosa 2nd to a
decrease in vascular permeability
– NOT for acute asthma
• Adverse effects: well tolerated
– Oropharyngeal candidiasis
– Dysphonia (hoarseness)
• Long term high dose – suppression of adrenal
– Not as severe as with oral steroids
• Can slow growth in children & adolescents
**Administer beta2 agonist first, then wait 5 minutes **
Beclomethasone (Beclovent, Vanceril)
Bedesonide (Pulmicort)
Ciclesonide (Alvesco)
Fluticasone (Flovent)
Triamcinolone acetonide (Azmacort)
Flunisolide (AeroBid)
Most clients with persistent asthma should receive
__________ to treat the underlying inflammation.
A. Inhaled/oral corticosteroid
B. Muscarinic agonist
C. Inhaled mast cell stabilizer
D. oral antileukotriene agent
Chronic Obstructive Pulmonary
Disease (COPD)
COPD Pathophysiology
Pharmacologic Treatment
Goals of Treatment:
• Reduce shortness of breath.
• Control coughing and wheezing.
• Prevent COPD exacerbations, or keep the
‘flare-ups’ from becoming life-threatening.
• MOA: Acetylcholine (ACh) causes bronchial
– Anticholinergics bind to the ACh receptor &
prevent ACh from binding with receptors in
bronchial tree.
– Anticholinergics actions are slow & prolonged,
therefore used to prevent bronchospasm.
– Anticholinergics cause airway dilation
Anticholinergic Agents
• Ipratropium bromide (Atrovent)
• Tiotropoium bromide (Spiriva)
• Action:
– Local effects
– Slow and prolonged action
– Used to prevent bronchoconstriction
– Usually not used for acute asthma exacerbation
Anticholingergic Bronchodilators
• Ipratropium bromide (Atrovent)
• Indication – COPD
• Pharmacokinetics- inhalation onset 15 min, peak 1-2 h,
duration 3-6 h, 1/2 life is 2 hour
• Pharmacodynamics - acetylcholine antagonist,
bronchodilation local, site-specific effect.
• Pharmaceuticals - aerosol or inhalant; dose 2 puffs (36 mcg)
qid, max 12 puffs/24 h
• Adverse Effects
– Usually not absorbed systemically
– If absorbed can cause
Dry mouth or dry throat
GI distress
– Common: cough, bad taste in mouth
Ipratropium Bromide (Atrovent):
Pregnancy B
Hypersensitivity to atropine
Prostatic hyperplasia or bladder neck
• Pedi safety < 12 yo not established.
Atrovent (ipratropium bromide): Nursing
• Ongoing pulmonary assessment
• Not for occasional use; do not change dose
• Do not spray in eyes
• If pt. is also on Beta2-agonist inhalers, tell pt. To
use first, then wait 5 minutes & use Atrovent
(ipratropium bromide).
Instruction on Use of Metered Dose Inhaler
w/o spacer (MDI)
• Getting ready
– Take off the cap and shake the inhaler hard.
– If you have not used the inhaler in a while, you may need to prime it. See the
instructions that came with your inhaler for how to do this.
– Breathe out all the way.
– Hold the inhaler 1 to 2 inches in front of your mouth (about the width of 2 fingers).
– Breathe in slowly
– Start breathing in slowly through your mouth, then press down on the inhaler 1
– Keep breathing in slowly, as deeply as you can.
• Hold your breath
– If you can, hold your breath as you slowly count to 10. This lets the medicine reach
deep into your lungs.
– If you are using inhaled, quick-relief medicine (beta-agonists), wait about 1 minute
before you take your next puff. You do not need to wait a minute between puffs for
other medicines.
– After using your inhaler, rinse your mouth with water, gargle, and spit. This helps
reduce side effects from your medicine.
Instruction on Use of Metered Dose
Keep your inhaler clean
Look at the hole where the medicine sprays out of your inhaler. If you see powder in or around the hole,
clean your inhaler.
Remove the metal canister from the L-shaped plastic mouthpiece.
Rinse only the mouthpiece and cap in warm water.
Let them air dry overnight.
In the morning, put the canister back inside. Put the cap on.
Do not rinse any other parts.
Replacing your inhaler
For control medicines you take each day, write on the canister the date you need to replace it. To figure
out this date, divide the number of puffs your canister contains by the number of puffs you take each day.
For example, say your new canister has 200 puffs (the number of puffs is listed on each canister) and your
doctor tells you to take 8 puffs each day. This canister will last 25 days. If you started using this inhaler on
May 1, replace it on or before May 25. Write May 25 on your canister.
Some inhalers come with counters on the canister. Keep an eye on the counter and replace the inhaler
before you run out of medicine.
Puff counters can also be bought at a drugstore or online.
Do not put your canister in water to see if it is empty. This does not work.
Bring your inhaler to your clinic appointments. Your doctor can make sure you are using it the right way.
Storing your inhaler
Store your inhaler at room temperature. It may not work well if it is too cold. The medicine in the canister
is under pressure. So make sure you do not get it too hot or puncture it.
National Asthma Education and Prevention Program Expert Panel Report 3:Guidelines for the Diagnosis and Management of Asthma
National Asthma Education and Prevention Program. How to use a metered-dose inhaler.
http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_tipsheets.pdf.Accessed May 8, 2014.
Using a Diskus Inhaler
Use of Dry Powder Inhaler (DPI)
Hold the dry powdered flat with one hand. Don’t shake it.
Put the thumb of your other hand on the thumb grip to slide the door open to find
the mouthpiece.
Place thumb on lever and push your thumb away from you as far as it will go until
you hear a click.
Turn your head to the side and breathe out-do not breathe into the inhaler.
Close your mouth tightly around the mouthpiece while holding the device flat
Breathe in fast and deep through the mouthpiece.
“Hold it like a hamburger-suck like a milkshake!”
After you breathe the medicine in, hold your breath for a count of 10. Then slowly
breathe out.
Close the device when you’re finished so it will be ready for your next dose.
You may not feel or taste the medicine.
Rinse your mouth out with water or brush your teeth after using dry powdered
Wipe the mouthpiece with a dry cloth after each use. Always keep the dry
powdered inhaler dry and never take it apart.
MDI w/ Spacer
Getting ready
Take the cap off inhaler and spacer.
Shake the inhaler well.
Attach the spacer to inhaler.
If inhaler not used in a while, may need to prime it.
Breathe out gently to empty lungs
Breathe in slowly
Put the spacer between your teeth and close your lips tightly around it.
Keep chin up.
Inhale slowly through mouth.
Spray 1 puff into the spacer by pressing down on the inhaler.
Keep breathing in slowly. Breathe as deeply as possible.
Hold breath
Take the spacer out of mouth.
Hold breath & count to 10, if possible.
Purse lips and slowly exhale through mouth.
After using inhaler, rinse mouth with water, gargle, and spit to reduce side effects.
MDI w/ Spacer
• Keep inhaler clean
• Look at the hole where the medicine sprays out of inhaler. If you see
powder in or around the hole, clean inhaler. First, remove the metal
canister from the L-shaped plastic mouthpiece. Rinse only the mouthpiece
and cap in warm water. Let them air dry overnight. In the morning, put the
canister back inside. Put the cap on. Do not rinse any other parts.
• Replacing inhaler
Write on canister the date inhaler needs to be replaced.
• Storing inhaler
• Store inhaler at room temperature. It may not work well if it is too cold.
The medicine in the canister is under pressure. So make sure not to get it
too hot or puncture it.
• National Asthma Education and Prevention Program Expert Panel Report
3:Guidelines for the Diagnosis and Management of Asthma
Antitussives, Expectorants, &
Mucolytic Agents
Drugs for Cough & Colds
• An agent that increases the flow of fluid in the
respiratory tract.
– Reduces the viscosity of bronchial & tracheal
– Facilitates secretions by the cough reflex & ciliary
• Indication - dry, nonproductive cough, mucous
• Pharmacokinetics: absorbed PO, metabolized liver,
excreted kidneys
• Pharmaceutics - syrup, tablet, liquid, capsule,
sustained-release capsule
• An expectorant found in many cough syrups
and used to decrease mucus viscosity and
convert a nonproductive cough into a
productive cough.
• Other names: glyceryl guaiacolate, guiatuss,
humibid, robitussin, anti-tuss, mucinex
Guaifenesin: Adverse Effects
• Life-threatening: None
• Common: None noted
• Infrequent: drowsiness
– stomach pain, diarrhea, vomiting and nausea
(with excessive use)
Guaifenesin:Nursing Management
• Pregnancy C
• Contact primary care provider
– Cough persists > 1 week
– High fever
– Rash
– Persistent HA
• Give with full glass of H2O to help liquefy & loosen mucus in
• Note - drug contains 3.5% to 10% alcohol
Antitussive Agents
• Non-opioid vs. Opioid Antitussive Agents
– Opioid antitussive agent is codeine
– Non-opioids are:
• dextromethorphan (Vicks-Formula 44,
Robitussin -DM)
• benzonatate (Tessalon Perles)
Antitussives: Benzonatate
• Benzonatate (Tessalon Perles)
• Indication: dry, hacking, nonproductive cough
interfering with rest & sleep
• Pharmacokinetics: onset 15-20 min, duration
3-8 h
Antitussives: Bezonatate
• Pharmacodynamics: anesthetizes stretch receptors
in respiratory passages, lungs, pleura (responsible for
cough reflex)
• Pharmaceutics: capsule
• S/E: drowsiness, chilliness, HA, GI upset,
constipation, burning sensation in eyes
• Paradoxical reaction- restlessness, insomnia,
euphoria, nervousness, tremors, convulsions, CNS
Benzonatate: Drug Interactions
• CNS depressants
• Nursing Management
– do not suppress
productive cough
– determine cause of
– do not operate car or
Dextromethorphan: Antitussive
• Pharmacodynamics: Suppresses cough reflex by
direct action of the cough center in the medulla.
• Almost equal in it’s antitussive potency to codeine,
but little or no CNS depression. Also, fewer GI
• Pharmacokinetics: action begins within 15-30
Dextromethorphan: Antitussive
• Contraindications
– do not use in patient receiving MAO inhibitors within the
preceding 2 weeks because of concomitant use can cause
decreased BP, coma, death
– Use with caution with asthma & other respiratory
problems - drug will immobilize secretions
– Syrup, tablets, & lozenges not recommended for children
under 2 yo.
– Pregnancy C category
Mucolytic Agents
• Acetylcysteine (Mucomyst, mucosil)
• Indication – abnormally viscous mucous secretions with acute
& chronic bronchopulmonary disease.
– pulmonary complications of CF.
– tracheostomy care.
– acetaminophen overdose
Mucolytic Agents
• Pharmacokinetics - aerosol absorbed from
pulmonary epithelium, PO absorbed GI; metabolism
• Pharmacodynamics – splits disulfide linkeage of mucoproteins; reduces
viscosity, facilitates removal of secretions - liquefies
– restores hepatic concentration of glutathione necessary
for inactivation of hepatotoxic acetaminophen
Mucolytic Agents
• Pharmaceutics - nebulization 20% solution diluted
with NS or sterile water, 10% undiluted: PO 5%
solution diluted in 1:3 ratio with coke or juice
• S/E: bronchospasms, stomatitis, rhinorrhea, N/V,
• Caution: bronchial asthma, elderly, debilitated
• Can cause bronchospasms
Acetylcysteine (Mucomyst)
• Know that drug maybe given via nebulizer, IV, orally, or
instilled into an endotracheal tube
• Offer a face cloth after inhalation – becomes sticky on
• Administer by mouth mixed with iced liquid & have
patients drink with a straw to minimize contact w/ the
taste buds on tongue
• About 17 doses over a 4-day period in acetaminophen
• Disguise odor of rotten eggs if given PO by mixing w/ 4
ounces of iced soft drink or juice & give w/ a straw
Drugs for Pulmonary
Arterial Hypertension
Pulmonary Arterial Hypertension
• Rare, progressive & potentially fatal disease of
the small pulmonary arteries
– Vasoconstriction, proliferation of smooth muscle
cells & endothelial cells; pulmonary thrombosis
– Cells proliferate & vascular remodeling leads to
progressive increase in pulmonary vascular
resistance & right ventricular failure -> death
Pulmonary Arterial Hypertension
Prostacyclin Analogs
• MOA: mimic actions of endogenous prostacyclin
which promotes:
– Vascular relaxation
– Suppresses growth of vascular smooth muscle cells
– Inhibits platelet aggregation
• Outcome
Lowers arterial pulmonary resistance
Decrease pulmonary arterial pressure
Increased exercise tolerance
Improve short term survival
Prostacyclin Analogs
• 3 drugs approved for management of PAH
– Epoprostenol (Flolan)
Half life very short – 6 minutes
Unstable at room temperature
Given continuously via a pump; start low & titrate up
Adverse effects:
– n/v (32%), flushing (58%), Headaches (49%)
– Treprostinil (Remodulin)
• Inhalation or continuous subcutaneous (SC) therapy
• Adverse effects for inhaled
– Cough (54%), headache (41%), throat irritation (25%), nausea
(19%), flushing (17%), dizziness (6%)
Prostacyclin Analogs
– Iloprost (Ventavis)
• Does not require continuous infusion
• Administered via oral inhalation
• Adverse effects:
– Cough (39%), headache (30%), flushing (27%), spasm of jaw
muscles (12%); hypotension w/ fainting (11%)
• Nursing implications
– Avoid drug in patients w/ SBP < 85 mm Hg
Endothelian-1 Receptor Antagonists
• Background
– There is a hormone, Endothelin-1 (ET-1) that promotes
vasoconstriction & proliferation of endothelial cells
• 2 receptors: ET-1 type A & ET-1 type B
– Type A activation causes vasoconstriction & cell proliferation
– Type B activation causes vasodilation
– In patients w/ PAH, the ET-1 is elevated
• Drugs – 2 drugs approved in this classification
– Improves exercise tolerance
– Delay symptom progression
– Does have severe adverse effects (Liver injury) &
contraindicated in pregnancy (fetal malformation)
Endothelian-1 Receptor Antagonists
• Drugs
– Bosentan (Tracleer)
• A nonspecific drug that blocks type A & type B ET-1
• Adverse effects
Hepatotoxicity (11% of patients had LFT’s 3X normal)
Fetal injury – Pregnancy Category X
Drug –drug interactions: glyburide (for diabetes)
Phosphodiesterase Type 5 Inhibitors
• MOA: PDE5 inhibitors reduce pulmonary
arterial pressure by causing dilation of
pulmonary blood vessels.
• 2 drugs approved
– Sildenafil
– tadalafil
Phosphodiesterase Type 5 Inhibitors
• Sildenafil (Revatio)
– Oral drug & IV preparation
– Reduces both pulmonary arteriole pressure &
pulmonary vascular resistance; suppresses
proliferation of pulmonary vascular smooth muscle
– Generally well tolerated
• Headaches, flushing, dyspepsia, priapism, transient visual
disturbances; hypotension
• DO NOT GIVE W/ NITRATES -> life threatening hypotension
Case Study (Cont.)
One of the attendees expresses concern regarding her
granddaughter’s asthma. The attendee tells the nurse that she is
afraid that she will not know which of her granddaughter's
medications to give first in case of an asthma attack. Which
medication should the nurse inform the attendee to administer
first for an acute asthma attack?
ipratropium (Atrovent)
albuterol (Proventil)
budesonide (Pulmicort Turbuhaler)
montelukast (Singulair)
Copyright © 2017, Elsevier Inc.
All rights reserved.
Lung Surfactant
Surfactant & Alveoli
Lung Surfactant
• Porcine extract of lung surfactant given to neonates w/
respiratory distress syndrome
• 3 drugs approved in US
– Poractant alfa (Curosurf)
– Calfactant (Infasurf)
– Beractant (Survanta)
• Administered via intratracheal tube
• Adverse effects:
– Bradycardia, oxygen desaturation (RT administration)
– Pulmonary hemorrhage, mucus plugging, endotracheal tube reflux
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