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Definitions
Route of Administration
Drug Categories
What do you Recommend
Calculations
Respiratory Care Plan

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Pharmacology
Drug
Medication
Pharmacotherapy
Synergism
Pharmacokinetic Phase
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Time Course and Deposition of a drug in the body
Ionized Drug (will limit systemic absorption)
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 Effects local to the airway
Non-Ionized Drug
 Diffuses across cell membrane into the bloodstream
Pharmacodynamic Phase
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Mechanism of action

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L/T ratio (Lung availability/Total Systemic availability ratio)
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Increased ratio indicates more meds delivered to lungs
Toxicology
LD 50
ED50
Therapeutic Index
Tachyphylaxis
Carcinogen
Teratogens

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Onset of Drug Action is Related to Route of
Administration
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IA (Intra-arterial)
IV (Intravenous)
IM (Intramuscular)
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Aerosol/Inhalation
Subcutaneous
Oral/Gatrointestinal
Topical
**If no IV is available, use ETT tube next**

ADVANTAGES
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Immediate onset at desired site
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Decreased side effects
 less systemic absorption
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Smaller doses of potent drugs
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Self-Administration
**Only disadvantage is that the delivered doses are not consistent**

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Wetting Agents or mucolytics
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Surface-active agents (surfactant)
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ACLS Drugs

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Bronchodilators
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Adrenergic Agents
Inhaled Anticholinergic
Agent
Xanthines
Antiinflammatory Agents
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Nonsteroidal
Corticosteroids
Nonsteroidal Antiasthma
Agents
Mucolytics/ Proteolytics
Agents
Saline (Bland)
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Diuretics Agents
Sedatives Agents
Analgesics Agents
Paralytics Agents
Surfactants Agents
Cardiac drugs/ACLS
Antimicrobials,
Antiinfectives,
Antibiotics

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 Most common group of drugs among aerosolized agents
 Active
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 Passive
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 Passive

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Sympathomimetic (cyclic 3’5’ AMP)
Anticholinergic (Block the bronchoconstricting effects of the parasympathetic system)
Xanthines (inhibit breakdown of cyclic 3’5’
AMP)
***Both sympathetic and parasympathetic receptors are found in the lung***

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Emergency system
Dominate during great stress
Adrenaline
(epinephrine)

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Alpha
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Vasoconstriction
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Mucosal edema
Blood vessels of mucus membranes/skeletal muscle
Beta-1
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Heart
 increased HR
Beta-2
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Airways
 Dilation of Bronchi

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Racemic epinephrine
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Vaso-pressors

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Inflammation due to increased capillary permeability=mucosal edema
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Not allergic response
Injury: smoke, fumes, steam
Trauma: Intubation/Extubation
Infection: croup, epiglottitis, bronchiolitis
Bleeding from bronchoscopy
Administered via SVN

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Neurotransmitter is norepinephrine
Many names
 Catecholamines
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Noncatecholamines
Sympathomimetic amines
Beta Agonist
Amine is an ammonium derivative; nitrogen with a hydrogen group replaced by an organic group

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Catecholamine
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Mixed beta-1 and beta-2 effects
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Alpha, and beta-1, and/or beta-2 effects
Non-Catecholamine
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Strong beta-2 specificity
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Newer beta agonists

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Acute bronchospasm
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Fast-acting
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Rescue agents
Chronic but stable
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Not used to treat acute episodes
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Peak response 3-5 hours
**NBRC hint: if the patient is in distress, give them a
SABA via SVN**

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A fast-onset medication (albuterol, levalbuterol) is used to treat a patient with acute bronchospasm. A long-duration medication (salmeterol, formoterol) is used to treat a patient with chronic, stable bronchospasm. A vasoconstricting medication
(racemic epinephrine) is used to treat airway edema or bleeding.

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Tremor*** most frequent
Palpitations, tachycardia
Headache
Increased BP
Nervousness and irritability
Dizziness
Nausea
↓ PaO
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2
---Why?
Worsening V/Q ratio

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Acetylcholine (neurotransmitter)
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Parasympatho
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Ipratropium bromide
(Atrovent)
Tiotropium Bromide
(Spiriva)

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Increased HR
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Decreased secretions

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1 st choice for apnea in babies

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Bronchodilator
Pulmonary vasodilation
Cardiac Stimulation
Skeletal muscle stimulation (enhanced diaphragmatic contractility)
CNS stimulation
Diuresis
Narrow therapeutic range (10-15 u/mL)

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Nonsteroidal antiinflammatory drugs
Corticosteroids

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Prophylactic drugs used in the treatment of asthma
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 Prevent degranulation of mast cell
 Prevent the receptor site from binding to antigen

Introduction of allergen
Mast cell degranulation
Addition of leukotrines

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Acetylcysteine (Mucomyst)
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Always give with a bronchodilator
Dornase Alfa (Pulmozyme)
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Used with CF patients with purulent secretions
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Breaks up the strands of DNA in sputum

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Sterile water
Saline
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0.9% is normal saline
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>0.9% is considered hypertonic but usually it is a 3-15% concentration
 Used for sputum inductions (don’t use mucomyst for a sputum induction!)

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If the patient has edema or hypertension.
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Lasix
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Diuril
Edecrin
If the patient has increased ICP
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Mannitol
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Ureaphil

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There will usually be at least one question that regards the use of a diuretic in a patient who is fluid overloaded, and the side effects of using a diuretic. A diuretic drug such as furosemide
(Lasix) tends to cause the loss of potassium through the kidneys. Know to check the serum
K+ level. Remember that the normal K+ level is
3.5 to 5.5 mEq/L . If the patient the signs of dangerous hypokalemia, know to recommend that replacement K+ be given.

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Decrease anxiety under a variety of circumstances
Amnestics (can’t remember)
Induce sleep
Terminate seizures (muscle relaxant)

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Benzodiazepine
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Versed, Valium, Xanax
Nonbarbiturate
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Noctec, Doriden
Barbiturate
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Phenobarbital, Seconal

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Medications that control or block pain after injury or a surgical procedure
Opioid drugs
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Morphine Sulfate
 Good for decreasing pain for patient on mechanical ventilation
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Codeine Phosphate
Dilaudid
Demerol
Darvon
***Reverse opioid analgesics with
Naloxone (Narcan)***

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There is usually a question about recommending a drug for pain control. If the patient has severe pain from trauma or surgery, recommend morphine sulfate or a similar narcotic analgesic agent. Remember that too much narcotic can cause apnea. Narcan is the reversing agent for a narcotic overdose.

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Can use with combative patients to facilitate mechanical ventilation
Depolarizing Blocker
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Succinylcholine
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Short acting
Cannot be reversed
Nondepolarizing Blockers
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Longer acting
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Pavulon
Vecruronium Bromide
Flaxedil
Tracrium

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Colfosceril Palmitate (Exosurf)
Beractant (Survanta)
Poractant Alfa (Curosurf)
Calfactant (Infasurf)

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Amiodarone
Beta Blockers
Calcium channel blockers
Calcium chloride
Dobutamine
Dopamine
Digitalis
Levophed
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Lidocaine
Decreases ventricular irritability
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Treat PVC’s and other arrhythmias
Procainamide
Propranolol
Nipride
ACLS
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Epinephrine
Vassopressin
Atropine
Sodium Bicarbonate
Magnesium Sulfate
Atropine

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Epinephrine (Adrenaline) is a first-line drug used in a CPR attempt. It is used during bradycarida, asystole, and ventricular fibrillation because it increases the heart rate, stroke volume, and vasoconstriction to raise blood pressure. (In addition, it is a bronchodilator).

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Antimicrobials
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Antibiotics
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Antimycobacterials
Antifungals
Antiviral
Antiinfectives
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Pentamidine
 Pneumocystis jiroveci (PCP)
Ribavirin
 RSV
Tobramycin
 Pseudomonas aeruginosa in CF patients
Zanamivir (Relenza)
 Influenza

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Know antimicrobial agents and what they are used to treat:
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Penicillin to treat gram-positive bacteria
Gentamicin to treat gram-negative bacteria
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Aerosolized tobramycin to treat Pseudomonas pneumonia in children with CF
Aerosolized pentamidine isethionate for prophylactic treatment of Pneumocystis carinii
Aerosolized ribavirin to treat RSV in young children
Isoniazid (INH) to treat Mycobaterium tuberculosis

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Bleeding from a bronchoscopy biopsy?

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Inhaled bronchodilators and corticosteroid drugs have not managed the patient’s problem.

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Prophylactic purposes to prevent an asthma attack
Contraindicated during an asthma attack

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Mucomyst is ordered.

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Average of 3 questions
Acute verses stable bronchospasm
Lasix needs K replacement
RSV or PCP
Premie: aminophylline or caffeine

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Drug Dilution
Volume and Concentration
Volume of Medication of Deliver Desired
Active Igredient

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How many milligrams are in 5ml of a 4% solution?
Convert % solution to mg/ml
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Multiply % solution valuetimes 10
 2% solution =20 mg/ml
Divide mg by 10 to get % solution
 5mg/ml=0.5% solution
4% solution = 40 mg/ml
40 mg/ml x 5 ml=200mg
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200mg/10=20% solution
How many milligrams are in 5 ml of a 4% solution?
40mg/mlx5ml=200mg

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You have 15ml of 20% Mucomyst. You want a 15% solution. How many ml will you have if you dilute it to achieve this%?
V1 x C1 = V2 x C2
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15 ml x 20% = V2 x 15%
15ml x 200 mg/ml = V2 x 150 mg/ml
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3000 mg = V2 x 150 mg/ml
3000 mg/150 mg/ml = V2
20 ml = V2

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How much 1:100 strength Isuprel would be needed to give a patient 2.5mg of active ingredient?
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Change concentration to a fraction
Convert grams to mg (i.e., 1g/100ml=1000mg/100ml)
Set up the equation 1000mg = 2.5mg
100ml Unknown
 1000mg x (unknown) = 250mg/ml
 Unknown=250mg/ml
 1000mg
 Unknown=0.25ml of Isuprel

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Which one of these drugs would be best to use to temporarily paralyze a patient to facilitate tracheal intubation?
a. atropine sulfate b. succinylcholine (anectine) c. Midazolam (versed) d. Pancuronium bromide (Pavulon)

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Which one of these drugs would be best to use to temporarily paralyze a patient to facilitate tracheal intubation?
a. atropine sulfate b. succinylcholine (anectine) c. Midazolam (versed) d. Pancuronium bromide (Pavulon)

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A patient has been paralyzed with vecuronium
(Norcuron) and is receiving mechanical ventilation. Which of the following ventilator monitoring alarms would be the most important?
a. low pressure b. high pressure c. inspired gas temperature d. I:E time

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A patient has been paralyzed with vecuronium
(Norcuron) and is receiving mechanical ventilation. Which of the following ventilator monitoring alarms would be the most important?
a. low pressure b. high pressure c. inspired gas temperature d. I:E time

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b.
c.
d.
Which of the following medications would be most indicated in the treatment of a patient with large amounts of thick secretions?
Salmeterol
Hypotonic saline
Acetylcysteine albuterol

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b.
c.
d.
Which of the following medications would be most indicated in the treatment of a patient with large amounts of thick secretions?
Salmeterol
Hypotonic saline
Acetylcysteine albuterol

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b.
c.
d.
While delivering a bronchodilating agent to a patient using a handheld nebulizer, you note the pulse increases from 72/min to 88/min over the first 5 min of therapy. Which of the following is the most appropriate action to take?
Stop the treatment immediately and notify the physician
Continue the treatment as ordered
Increase the inspiratory pressure for the remainder of the treatment
Give the remainder of the treatment with saline only

 a.
b.
c.
d.
While delivering a bronchodilating agent to a patient using a handheld nebulizer, you note the pulse increases from 72/min to 88/min over the first 5 min of therapy. Which of the following is the most appropriate action to take?
Stop the treatment immediately and notify the physician
Continue the treatment as ordered
Increase the inspiratory pressure for the remainder of the treatment
Give the remainder of the treatment with saline only

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After administering a bland aerosol treatment to a patient, the RT auscultates bilateral rhonchi. The therapist should recommend which of the following?
a. discontinue the treatment and initiate IPPB therapy b. Encourage the patient to deep breath and cough c. initiate bronchodilator therapy d. discontinue therapy

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After administering a bland aerosol treatment to a patient, the RT auscultates bilateral rhonchi. The therapist should recommend which of the following?
a. discontinue the treatment and initiate IPPB therapy b. Encourage the patient to deep breath and cough c. initiate bronchodilator therapy d. discontinue therapy

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You are having difficulty intubating a combative patient in the emergency department. The RT should recommend delivery of which drug to facilitate intubation?
a. Succinylcholine (anectine) b. cromolyn sodium c. atropine sulfate d. epinephrine

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You are having difficulty intubating a combative patient in the emergency department. The RT should recommend delivery of which drug to facilitate intubation?
a. Succinylcholine (anectine) b. cromolyn sodium c. atropine sulfate d. epinephrine

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An RT is called to the ED to assist with the intubation of an alert, agitated patient in respiratory failure. Two intubation attempts were unsuccessful. Which of the following drugs would best facilitate intubation?
a. nifedipine (Verapamil) b. lorazepam (Ativan) c. propranolol (Inderal) d. nitroprusside (Nipride)

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An RT is called to the ED to assist with the intubation of an alert, agitated patient in respiratory failure. Two intubation attempts were unsuccessful. Which of the following drugs would best facilitate intubation?
a. nifedipine (Verapamil) b. lorazepam (Ativan) c. propranolol (Inderal) d. nitroprusside (Nipride)

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A patient in the ICU has been receiving mechanical ventilation for 2 weeks. The sputum has changed from white to green and sweet smelling. Which of the following should an RT recommend?
a. antibiotic therapy b. antiviral therapy c. antiprotozoan therapy d. anti-inflammatory therapy

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A patient in the ICU has been receiving mechanical ventilation for 2 weeks. The sputum has changed from white to green and sweet smelling. Which of the following should an RT recommend?
a. antibiotic therapy b. antiviral therapy c. antiprotozoan therapy d. anti-inflammatory therapy

 a.
b.
c.
d.
Which of the following could be recommended to reduce systemic arterial blood pressure and reduce ventricular preload?
Sodium nitroprusside (Nipride)
Dobutamine (Dobutrex)
Dopamine (Intropin)
Propranolol (Inderal)

 a.
b.
c.
d.
Which of the following could be recommended to reduce systemic arterial blood pressure and reduce ventricular preload?
Sodium nitroprusside (Nipride)
Dobutamine (Dobutrex)
Dopamine (Intropin)
Propranolol (Inderal)

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A 68-year-old man with a history of COPD is admitted to the hospital for increasing shortness of breath and a nonproductive cough. Chest auscultation reveals expiratory wheezes. Which of the following is the most appropriate to improve the patient’s clinical condition?
a. beclomethasone (Vanceril) b. ipratropium bromide (Atrovent) c. amoxicillin (Augmentin) d. cromolyn sodium (Intal)

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A 68-year-old man with a history of COPD is admitted to the hospital for increasing shortness of breath and a nonproductive cough. Chest auscultation reveals expiratory wheezes. Which of the following is the most appropriate to improve the patient’s clinical condition?
a. beclomethasone (Vanceril) b. ipratropium bromide (Atrovent) c. amoxicillin (Augmentin) d. cromolyn sodium (Intal)

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A patient is admitted to the hospital with asthma triggered by a pulmonary infection.
The patient has coughed up mucus plugs. It is most appropriate to administer: a. a bronchodilator with strong alpha stimulation b. aerosolized ipratropium bromide (Atrovent) c. mucolytic therapy followed by high humidity d. a bronchodliator followed by high humidity

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A patient is admitted to the hospital with asthma triggered by a pulmonary infection.
The patient has coughed up mucus plugs. It is most appropriate to administer: a. a bronchodilator with strong alpha stimulation b. aerosolized ipratropium bromide (Atrovent) c. mucolytic therapy followed by high humidity d. a bronchodliator followed by high humidity

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An MDI is ordered for a patient receiving mechanical ventilation. Which of the following is the most appropriate way to administer the bronchodilator?
a. insert the MDI and spacer in the expiratory limb of the ventilator b. Place the MDI and spacer in the inspiratory limb, close to the Y c. increase the mandatory rate during the MDI treatment d. disconnect the ventilator circuit and discharge the MDI directly into the endotracheal tube

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An MDI is ordered for a patient receiving mechanical ventilation. Which of the following is the most appropriate way to administer the bronchodilator?
a. insert the MDI and spacer in the expiratory limb of the ventilator b. Place the MDI and spacer in the inspiratory limb, close to the Y c. increase the mandatory rate during the MDI treatment d. disconnect the ventilator circuit and discharge the MDI directly into the endotracheal tube

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A patient with known reversible airway disease administers two puffs from his MDI. After the treatment an RT measures the patient’s peak flow and notices that is has only increased marginally from pre-administration. The therapist should: a. add a spacer to the MDI b. change the medication to a different beta-agonist c. administer by a small-volume nebulizer d. contact the attending physician of the peak flow results

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A patient with known reversible airway disease administers two puffs from his MDI. After the treatment an RT measures the patient’s peak flow and notices that is has only increased marginally from pre-administration. The therapist should: a. add a spacer to the MDI b. change the medication to a different beta-agonist c. administer by a small-volume nebulizer d. contact the attending physician of the peak flow results