CHAPTER 37
Bronchodilators and Other
Respiratory Drugs
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Mosby items
derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Falland
2012
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Diseases of the Lower
Respiratory Tract
 COPD
 Asthma
 Emphysema
 Chronic bronchitis
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Bronchial Asthma
 Recurrent and reversible shortness of breath
 Occurs when the airways of the lungs become
narrow as a result of:
 Bronchospasms
 Inflammation of the bronchial mucosa
 Edema of the bronchial mucosa
 Production of mucus
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Bronchial Asthma (cont’d)
 Alveolar ducts/alveoli remain open, but airflow to
them is obstructed
 Symptoms
 Wheezing
 Difficulty breathing
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Asthma
 Three categories
 Allergic
 Idiopathic
 Mixed allergic-idiopathic
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Asthma (cont’d)
 Status asthmaticus
 Prolonged asthma attack that does not respond to
typical drug therapy
 May last several minutes to hours
 Medical emergency
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Chronic Bronchitis
 Continuous inflammation of the bronchi and
bronchioles
 Often occurs as a result of prolonged exposure to
bronchial irritants
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Emphysema
 Air spaces enlarge as a result of the destruction
of alveolar walls
 The surface area where gas exchange takes
place is reduced
 Effective respiration is impaired
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Drugs Used to Treat Asthma
 Long-term control
 Leukotriene receptor antagonists
 Inhaled steroids
 Long-acting beta2-agonists
 Quick relief
 Intravenous systemic corticosteroids
 Short-acting inhaled beta2-agonists
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Bronchodilators and
Respiratory Drugs
 Bronchodilators
 Beta-adrenergic agonists
 Xanthine derivatives
 Anticholinergics
 Leukotriene receptor antagonists
 Corticosteroids
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Bronchodilators: BetaAgonists
 Large group, sympathomimetic (adrenergic)
 Used during acute phase of asthmatic attacks
 Quickly reduce airway constriction and restore
normal airflow
 Stimulate beta2-adrenergic receptors throughout
the lungs
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Bronchodilators: BetaAgonists (cont’d)
Three types
 Nonselective adrenergics
 Stimulate alpha, beta1 (cardiac), and beta2
(respiratory) receptors
 Example: epinephrine
 Nonselective beta-adrenergics
 Stimulate both beta1 and beta2 receptors
 Example: metaproterenol (Alupent)
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Bronchodilators:
Beta-Agonists (cont’d)
Three types (cont’d)
 Selective beta2 drugs
 Stimulate only beta2 receptors
 Example:
 ALBUTEROL (PROVENTIL, VENTOLIN)

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FAST ACTING – RESCUE INHALER
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Beta-Agonists:
Mechanism of Action
 Begins at the specific receptor stimulated
 Ends with dilation of the airways
 Activation of beta2 receptors activates cyclic
adenosine monophosphate (cAMP), which relaxes
smooth muscle in the airway and results in
bronchial dilation and increased airflow
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Beta-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
 Used to produce uterine relaxation to prevent
premature labor
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Beta-Agonists: Adverse
Effects
 Alpha and beta 1, 2 (epinephrine)
 Insomnia
 Restlessness
 Anorexia
 Vascular headache
 Hyperglycemia
 Tremor
 Cardiac stimulation
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Beta-Agonists: Adverse
Effects (cont’d)
 Beta1 and beta2 - metaproterenol (Alupent)
Cardiac stimulation
 Tremor
 Anginal pain
 Vascular headache
 Hypotension

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Beta-Agonists: Adverse
Effects (cont’d)
 Beta2 (albuterol)
 Hypotension OR hypertension
 Vascular headache
 Tremor
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Nursing Implications (cont’d)
 Perform a thorough assessment before beginning
therapy, including:
 Skin color
 Baseline vital signs
 Respirations (should be between 12 and 24





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breaths/min)
Respiratory assessment, including pulse oximetry
Sputum production
Allergies
History of respiratory problems
Other medications
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Nursing Implications (cont’d)
 Teach patients to take bronchodilators exactly as
prescribed
 Ensure that patients know how to use inhalers
and MDIs, and have patients demonstrate use of
the devices
 Monitor for adverse effects
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Nursing Implications (cont’d)
 Monitor for therapeutic effects
 Decreased dyspnea
 Decreased wheezing, restlessness, and anxiety
 Improved respiratory patterns with return to normal
rate and quality
 Improved activity tolerance
 Decreased symptoms and increased
ease of breathing
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Nursing Implications (cont’d)
 Beta-agonist derivatives
 Albuterol, if used too frequently, loses its
beta2-specific actions at larger doses
 As a result, beta1 receptors are stimulated,
causing nausea, increased anxiety,
palpitations, tremors, and increased heart
rate
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Inhalers: Patient Education
 For any inhaler prescribed, ensure that the
patient is able to self-administer the
medication
 Provide demonstration and return
demonstration
 Ensure that the patient knows the correct
time intervals for inhalers
 Provide a spacer if the patient has difficulty
coordinating breathing with inhaler
activation
 Ensure that the patient knows how to keep
track of the number of doses in the inhaler
device
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METERED DOSE INHALER
OPTI CHAMBER (SPACER)
NEBULIZER
NEBULIZED MEDICATION
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DRY POWDER INHALER
Peak Flow Meter
Anticholinergics
 Ipratropium bromide (Atrovent) and tiotropium
(Spiriva)
 Slow and prolonged action
 Used to prevent bronchoconstriction
 NOT used for acute asthma exacerbations!
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Anticholinergics:
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
dilate
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Anticholinergics: Adverse
Effects







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Dry mouth or throat
Nasal congestion
Heart palpitations
Gastrointestinal distress
Headache
Coughing
Anxiety
No known drug interactions
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Bronchodilators:
Xanthine Derivatives
 Plant alkaloids: caffeine, theobromine, and
theophylline
 Only theophylline is used as a bronchodilator
 Synthetic xanthines: aminophylline and
dyphilline
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Xanthine Derivatives:
Drug Effects
 Also cause cardiovascular stimulation:
increased force of contraction and increased
heart rate, resulting in increased cardiac
output and increased blood flow to the
kidneys (diuretic effect)
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Xanthine Derivatives:
Drug Effects (cont’d)
 Cause bronchodilation by relaxing smooth muscle
in the airways
 Result: relief of bronchospasm and greater airflow
into and out of the lungs
 Also cause CNS stimulation
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Xanthine Derivatives:
Indications
 Dilation of airways in asthmas, chronic bronchitis,
and emphysema
 Mild to moderate cases of acute asthma
 Adjunct drug in the management of COPD
 Not used as frequently because of potential for
drug interactions and variables related to drug
levels in the blood
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Xanthine Derivatives:
Adverse Effects
 Nausea, vomiting, anorexia
 Gastroesophageal reflux during sleep
 Sinus tachycardia, extrasystole, palpitations,
ventricular dysrhythmias
 Transient increased urination
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Xanthine Derivatives: Nursing
Implications
 Contraindications: history of PUD or
GI disorders
 Cautious use: cardiac disease
 Timed-release preparations should not be
crushed or chewed (cause gastric irritation)
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Xanthine Derivatives: Nursing
Implications (cont’d)
 Report to physician:
 Palpitations
 Weakness
 Convulsions
 Nausea
 Dizziness
 Vomiting
 Chest pain
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Xanthine Derivatives: Nursing
Implications (cont’d)
 Be aware of drug interactions with cimetidine,
oral contraceptives, allopurinol, certain
antibiotics, others
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Leukotriene Receptor Antagonists
(LTRAs)
 Newer class of asthma medications
 Currently available drugs
 montelukast (Singulair)
 zafirlukast (Accolate)
 zileuton (Zyflo)
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LTRAs:
Mechanism of Action
 Leukotrienes are substances released when a
trigger, such as cat hair or dust, starts a series
of chemical reactions in the body
 Leukotrienes cause inflammation,
bronchoconstriction, and mucus production
 Result: coughing, wheezing, shortness
of breath
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LTRAs:
Mechanism of Action (cont’d)
 LTRAs prevent leukotrienes from attaching to
receptors on cells in the lungs and in
circulation
 Inflammation in the lungs is blocked, and
asthma symptoms are relieved
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LTRAs:
Drug Effects
 By blocking leukotrienes:
 Prevent smooth muscle contraction of the
bronchial airways
 Decrease mucus secretion
 Prevent vascular permeability
 Decrease neutrophil and leukocyte
infiltration
to the lungs, preventing inflammation
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LTRAs: Indications
 Prophylaxis and chronic treatment of asthma in
adults and children older than age 12
 NOT meant for management of acute asthmatic
attacks
 Montelukast is approved for use in children ages
2 and older, and for treatment of allergic rhinitis
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LTRAs: Adverse Effects
 Zileuton
 Headache, dyspepsia, nausea, dizziness,
insomnia, liver dysfunction
 Zafirlukast
 Headache, nausea, diarrhea, liver dysfunction
 Montelukast has fewer adverse effects
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LTRAs:
Nursing Implications
 Ensure that the drug is being used for chronic
management of asthma, not acute asthma
 Teach the patient the purpose of the therapy
 Improvement should be seen in about
1 week
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LTRAs:
Nursing Implications (cont’d)
 Advise patients to check with physician before
taking over-the-counter or prescribed
medications—there are many drug interactions
 Assess liver function before beginning therapy
 Teach patient to take medications every night on
a continuous schedule, even if symptoms improve
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Corticosteroids
 Antiinflammatory properties
 Used for chronic asthma
 Do not relieve symptoms of acute
asthmatic attacks
 Oral or inhaled forms
 Inhaled forms reduce systemic effects
 May take several weeks before full
effects are seen
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Corticosteroids:
Mechanism of Action
 Stabilize membranes of cells that release
harmful bronchoconstricting substances
 These cells are called leukocytes, or white
blood cells
 Increase responsiveness of bronchial smooth
muscle to beta-adrenergic stimulation
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Inhaled Corticosteroids
 beclomethasone dipropionate
(Beclovent, Vanceril)
 triamcinolone acetonide (Azmacort)
 dexamethasone sodium phosphate (Decadron
Phosphate Respihaler)
 fluticasone (Flovent, Flonase)
 Others
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Inhaled Corticosteroids:
Indications
 Treatment of bronchospastic disorders
that are not controlled by conventional
bronchodilators
 NOT considered first-line drugs for management
of acute asthmatic attacks
or status asthmaticus
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Inhaled Corticosteroids:
Adverse Effects
 Pharyngeal irritation
 Coughing
 Dry mouth
 Oral fungal infections
 Systemic effects are rare because low doses are
used for inhalation therapy
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Inhaled Corticosteroids:
Nursing Implications
 Contraindicated in patients with psychosis,
fungal infections, AIDS, TB
 Teach patients to gargle and rinse the mouth
with lukewarm water afterward to prevent the
development of oral fungal infections
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NURSING CONSIDERATIONS: ALL
INHALED MEDICATIONS
 5 MINUTES BETWEEN DRUGS
 BRONCHODILATORS FIRST
 RINSE MOUTH AFTER STEROIDS
 USE FAST ACTING INHALED MED FOR
ACUTE EPISODES
*ALBUTEROL – RESCUE
INHALER
Inhaled Corticosteroids:
Nursing Implications (cont’d)
 Teach patients to monitor disease with a
peak flow meter
 Encourage use of a spacer device to
ensure successful inhalations
 Teach patient how to keep inhalers and
nebulizer equipment clean after uses
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