In order to achieve optimum benefit of inhaled drugs, the nurse should instruct patients to take their respiratory medications in the order listed on this paper. Physicians try to maintain their patients on inhaled medications versus oral drugs because there are fewer systemic side effects with inhaled medications. A valved aerosol holding device such as the Aerochamber and the Optichamber should be used with a metered dose inhaler (MDI) for maximum absorption and effectiveness. When a MDI is used without a spacer, only
10% of the medication reaches the patient. When a spacer is used, 25% of medication reaches the lungs. Patient teaching in an integral part of using MDIs correctly. In 2% of research studies, individuals using MDIs failed to remove the cap before using! Wash all inhalation equipment except for medication canister at least every 24 hours to prevent infection. Never share inhalers.
Recently, environmental consciousness has promoted the evolution of dry powder inhalers (DPI) to dispense medications that were traditionally offered as “wet” medications through an MDI. Dry inhalers provide a more uniform aerosol particle size unlike MDIs. DPIs do not require a spacer and use no propellants so they are environmentally safe. DPIs are less temperature sensitive than MDIs. However, they are sensitive to increased humidity. Therefore, it is advisable that the medication not be stored in the bathroom. DPIs dispense medications more uniformly and efficiently than
MDIs. Problem with DPIs is that 10% of all patients do not successfully puncture the dry
“blister” during administration. In the not too distant future, environmental concerns of propellants may virtually eliminate MDIs in favor of DPIs.
Bronchodilators
Short acting and long acting beta agonists: These medications open up the air passages via bronchodilation. They relax smooth muscles that line the walls of the bronchi and make the airways wider and easier for air to move through. If the patient is on several inhalers, bronchodilators should be used first. Bronchodilators prepare the lungs so that other drugs can more easily enter the lungs (ie steroids and preventative medications).
More than one bronchodilator can be used because the different drugs have different lengths of action. Bronchodilators can be given orally, parenterally, or inhaled via a DPI,
MDI, or nebulizer. Fast acting “rescue” bronchodilators are used for patients in respiratory distress.
Anticholinergics: a special classification of bronchodilator by inhibiting parasympathetic tone and keeps the airways from constricting which opens airways by relaxing smooth muscle bands on the outside of the airway. They have a very similar action to beta agonists discussed above.
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Corticosteroids
These medications may be used in the treatment of lung disease to prevent and control inflammation. They help ease breathing by reducing swelling in the lining of air passages and reduce mucous production. These medications must be used on a regular basis to be effective. They are not rescue drugs. Inhaled steroid are used to prevent breathing problems and are therefore not effective in acute attacks. Remember, bronchodilators are used for immediate relief. Steroids are inhaled or can be taken orally or parenterally. Studies show that oral prednisone should be given every day at 3:00pm to coincide with circadian rhythms of epinephrine and cortisol. This has been shown to prevent patients from awakening with asthmatic attacks during the night.
With all steroids given via a MDI and DPI , instruct patients to always gargle and rinse mouth with water after using inhalers containing steroids. Do not swallow the water (thrush). Good oral hygiene is essential to prevent yeast infection.
Preventative Medications
These medications help prevent allergic reactions that cause bronchconstriction or spasm of the airways. They also prevent inflammation by inhibiting the release of histamine.
Mast cell stabilizer. For maximum effectiveness, these medications must be taken at regular intervals everyday, even if the patient is symptom free.
Leukotriene Modifiers: P reventative.
Leukotriene is 1000x more potent than histamine as a bronchoconstrictor. These drugs work for 50% of the patients in 4-6 weeks as a preventative.
Miscellaneous
Best lung of the day is usually at 1600 and worst lung of the day is at 0400 due to circadian rhythm excretion of endogenous steroids.
In 2001, governor of Illinois signed into law the right of public school children to carry and self-administer “rescue” asthma medications on school grounds. Prior to this law children has to obtain these medications from a school nurse or administrator, which wasted precious time. Doctor must write an order yearly for this to occur.
Smoking Cessation Drugs
Varenicline (Chantix)
Wellbutrin (Zyban)
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