Candy lips pump before and after

Drugs for the Treatment of Respiratory Disorders

N180 Pharmacology

1

Objectives

1. Discuss the nurse’s role regarding the nonpharmacologic

control of pulmonary disorders through patient teaching.

2. Describe the nurse’s role in the pharmacological treatment

of pulmonary disorders.

3. Categorize drugs used in the treatment of pulmonary

disorders based on their classification and mechanism of

action.

4. Discuss the mechanisms of administration for

pharmacological management of pulmonary disorders.

2

The Respiratory System

3

Anatomy of the Respiratory System

Upper Respiratory Tract

Nares, nasal cavity, pharynx, and larynx

Air enters through the upper airway, these structures help trap particulate matter and pathogens so that they do not make it to the lower airway.

Lower Respiratory Tract

Trachea, bronchi, bronchioles, alveoli

Gas exchange occurs here.

Ventilation/Perfusion

Ventilation is the process of air movement (inspiration and expiration)

Perfusion is the blood flow to the alveolar capillary bed where gas exchange takes place.

4

Upper Respiratory Disorders Colds and Allergic Rhinitis

The common cold and allergic rhinitis are common disorders of the nasopharyngeal tract.

Allergic rhinitis is often called hay fever and is caused by pollen or a foreign substance.

Symptoms of the common cold include rhinorrhea (watery nasal discharge), congestion, cough, and increased mucous.

Bacterial infections may cause nasal discharge to become tenacious, mucoid, and yellow/green.

Drug therapy involves antihistamines, decongestants, antitussives, expectorants, and mucolytics.

5

Non-Pharmacologic Management of Upper Respiratory Disorders

Avoid known triggers.

Drink lots of fluid

Rest

Practice Breathing Exercises

Neti Pots

Hard candy for cough

6

Pharmacologic Management of Respiratory Disorders

Preventer vs. Reliever

Treatment goal is relieve symptoms and prevent reoccurrence. This may take multiple medications.

Prevention drugs include H1 receptor antagonists, intranasal corticosteroids, and mast cell stabilizers and are targeted at preventing symptoms from occurring.

Reliever drugs include H1 receptor antagonists, decongestants, antitussives, expectorants, and mucolytics and are targeted at relieving unpleasant symptoms.

7

Antihistamines Prototypes: diphenhydramine, cetirizine

1st generation agent: diphenhydramine, 2nd generation agent: cetirizine

MOA: block H1 receptors resulting in the blockage of histamine release during allergic reactions.

Therapeutic Use: Mild allergic reactions, motion sickness, insomnia, often combined with decongestants (both a preventer and reliever)

Complications: sedation (common, will taper off), anticholinergic effects (dry mouth, constipation), GI upset (N/V, constipation), urinary retention, tachycardia, blurred vision, paradoxical excitation in children

8

Antihistamines Prototypes: diphenhydramine, cetirizine

Contraindications/Precautions: asthma, cardiac disease, seizure disorders, renal disease, urinary retention, open-angle glaucoma, hypertension, BPH (anticholinergic effects)

Interactions: increased CNS depression with alcohol, opioids, benzodiazepines

Administration: Oral, intranasal, IV. Best taken at bedtime with food due to drowsiness. Avoid any activities that require alertness (driving).

Nursing Considerations: Ensure client takes sips of water, sucks on sugarless hard candies (dry mouth) and increased fluid/fiber intake (constipation).

9

1st Generation vs. 2nd Generation

10

1st generation antihistamines are more likely to cause sedation and anticholinergic effects.

Additionally, the effects of 2nd generation antihistamines last longer.

Nursing Process: Antihistamines

Assessment: baseline vitals, drug therapies, history of constipation and urinary retention, allergens

Diagnosis: hypoxemia, decreased gas exchange, airway obstruction, discomfort

Planning: Patient will have decreased nasal congestion, mucosal secretions, and cough.

Interventions/Education: give with food at bedtime, avoid driving and CNS depressants, monitor children and elderly adults for complications

Evaluation: Relief of allergic symptoms

11

Additional Antihistamines and Their Uses

Promethazine (Phenergan): Used for nausea/emesis (blocks histamine release in the stomach)

Dimenhydrinate (Dramamine): used 30 minutes prior to events known to induce motion sickness (blocks histamine in the vomiting center of the brain-available in many forms)

Many other uses: Parkinson’s, insomnia, urticaria, rashes

12

Nasal Glucocorticoids Prototype: mometasone (Nasonex)

MOA: Decrease inflammation associated with allergic rhinitis

Other agents: fluticasone, triamcinolone, budesonide

Therapeutic Use: 1st line treatment for nasal congestion; reduce the effects of allergic rhinitis (sneezing, nasal itching, rhinorrhea)

Complications: minimal; most common is sore throat, nose bleed, headache, burning sensation in the nose

No significant precautions/interactions as the drug is delivered to site of action.

Administration: Teach the patient how to use metered-dose spray devices; should be taken daily with/without symptoms

May take up to 7-21 days to achieve peak response.

Client should take inhaled glucocorticoid AFTER taking decongestant in order to clear nasal passages first

13

Intransal and Systemic Decongestants Prototypes: oxymetazoline (Afrin), pseudophedrine (Sudafed)

MOA: stimulate the alpha-1 receptors of the sympathetic nervous system, causing reduction in the inflammation of the nasal mucosa.

Therapeutic Use: rhinitis (allergic or non-allergic), sinusitis, colds

Complications: rebound congestion (intranasal only), CNS stimulation (more common with oral agents), vasoconstriction

Contraindications/Precautions: cardiovascular disorders (due to vasoconstriction)

Administration: Teach intranasal administration, pseudophedrine requires identification at purchase as it can be converted to amphetamine

Nursing Considerations: taper use of intranasal forms over 3-5 days to avoid rebound congestion, often combined with antihistamines in cold medication preparations

14

Antitussives Prototypes: codeine (opioid), dextromethorphan (non-opioid)

MOA: suppresses the cough reflex by increasing the cough threshold in the CNS.

Therapeutic Use: nonproductive cough suppression

Complications: CNS depression (drowsiness, dizziness, respiratory depression), GI distress (N/V, constipation), opioid abuse *all complications are more common with opioid forms*

Contraindications/Precautions: Codeine is schedule II normally, but when used with other antitussives it is schedule V, respiratory depression, asthma, alcohol use, liver/kidney problems

Administration: monitor after dosage for safety (ambulation), monitor respiratory status, avoid activities that require alertness, take oral forms with food, increase fluids and fiber, use only short term

Available forms include capsules, lozenges, liquids, syrups (may contain alcohol and glucose)

15

Expectorants Prototype: guaifenesin (Mucinex)

MOA: promotes increase cough production by increasing and thinning mucous secretions, this mobilizes the secretions and allows the patient to eliminate them by coughing

Therapeutic Use: often combined with antitussives/decongestants for treatment of colds, rhinitis, cough

Complications: GI upset, drowsiness and dizziness, allergic reaction (rash)

Contraindications/Precautions: asthma (may cause bronchospasm), some forms contraindicated in children

Administration: available in tablets (no crushing) and capsules (can sprinkle on food), report cough lasting longer than one week, take with food and a full glass of water

Nursing Considerations: increase fluid intake throughout the day, stop if a rash develops and notify provider, ensure client is aware of contents of all combination cold medications

16

Mucolytics Prototype: acetylcysteine (Mucomyst)

MOA: directly breaks down and thins mucous to enhance the flow of secretions in the respiratory passages.

Therapeutic Use: acute and chronic pulmonary disorders, cystic fibrosis, antidote for acetaminophen overdose

Complications: aspiration/bronchospasm with oral forms, dizziness, drowsiness, hypotension, tachycardia, hepatotoxicity

Contraindications/Precautions: CNS depression, renal/liver disease

Administration: oral/inhalation/IV, this medication stinks-watch out for emesis/aspiration (stop treatment), warn patient they will cough, monitor LFT’s (AST/ALT)

17

Cold Remedies

18

Nursing Process: Cold Remedies

Assessment: any history of hypertension/cardiac disease, baseline vitals, cardiac/respiratory status, drug therapies

Diagnosis: hypoxemia, decreased gas exchange, airway obstruction, fatigue, discomfort

Planning: Patient’s nasal congestion will be relieved and patient will be free from secondary bacterial infections.

Interventions/Education: monitor vitals, observe secretions, avoid activities that require alertness, limit length of use of the medications, monitor combination cold medicine use for drug overlap, drink water, rest, avoid others (infectious), avoid airway irritants

Evaluation: Free from cough, congestion, and fever. Good fluid intake and rest.

19

Lower Respiratory System

Central chemoreceptors found in the medulla respond to an increase in CO2 and a decrease in pH of the blood by increasing ventilation.

Peripheral chemoreceptors found in the major arteries (aorta, carotids) respond to changes in oxygen levels. Low levels stimulate the respiratory center in the medulla and ventilation is increased.

The airways are lined with smooth muscle. Contraction of this muscles leads to bronchoconstriction (restricted airway) and relaxation of this muscle leads to bronchodilation (open airway).

20

Autonomic Nervous System Control of Respiratory Function

The sympathetic nervous system is made up of alpha and beta receptors that are activated by the hormone epinephrine.

When the beta2 receptors of the lungs are activated by epinephrine, the smooth muscle relaxes and the airway opens.

When the vagus nerve (part of the parasympathetic nervous system) is activated, acetylcholine is released and the smooth muscle constricts, restricting the airway.

21

Chronic Obstructive Pulmonary Disease

Asthma: an airway disorder triggered by stimuli (stress, allergens, illness, pollutants) leading to inflamed, edematous, constricted airways. This leads to wheezing, coughing dyspnea, chest tightness, and bronchospasm.

Chronic Bronchitis: lung disease caused by smoking or chronic lung infections that leads to bronchial inflammation and excessive mucous secretion.

Emphysema: lung disease caused by smoking where the bronchioles become plugged with mucus , the alveoli enlarge, and air becomes trapped in the expanded alveoli leading to CO2 retention.

22

Comparing Bronchitis and Emphysema

23

Bronchial Asthma

Allergens attach themselves to mast cells and and basophils, and this leads to the release of histamine, cytokines, serotonin, and leukotrienes.

These substances stimulate bronchial constriction, mucous secretions, inflammation, and pulmonary congestion.

Drugs used to treat COPD include:

Bronchodilators: albuterol, ipratropium, theophylline

Inflammatory Mediators: beclomethasone, prednisone, montelukast, cromolyn

Expectorants: acetylcysteine

Antibiotics if bacterial infection is suspected

24

Asthma

25

26

Beta Adrenergic Agonists Prototype: albuterol (Ventolin), salmeterol

MOA: activate the beta2 receptors in the bronchial smooth muscle resulting in bronchodilation

Therapeutic Use: short-acting beta agonists (albuterol) are used to prevent exercise induced bronchospasm, treat acute bronchospasm and asthma, and to treat status asthmaticus, long-acting beta agonists (salmeterol) are used for long-term control of asthma

Complications: tachycardia, angina, nervousness, restlessness, anxiety, tremors, hypokalemia and hyperglycemia (with prolonged use)

27

Beta Adrenergic Agonists Prototype: albuterol (Ventolin)

Contraindications/Precautions: Dysrhthmia, coronary diseases, cardia disease, hypertension, hyperthyroidism, diabetes

Interactions: Beta blockers will block the effects of this drug, certain antidepressants can increase the risk of tachycardia

Administration/Nursing Care: teach patients how to use a nebulizer or inhaler, albuterol should be taken before all other inhaled drugs (opens airway), SABA’s are used for acute attacks only, LABA’s are used for long term control/prevention of asthma, keep a log of usage of SABA’s

28

Anticholinergics Prototype: ipratropium (Atrovent)

MOA: blocks muscarinic receptors (parasympathetic nervous system) of the bronchi, resulting in bronchodilation

Therapeutic Use: long term treatment/prevention of acute bronchospasm

Complications: dry mouth, hoarseness

Contraindications/Precautions: allergy to peanuts (contains soy lecithin), glaucoma and BPH (due to anticholinergic effects)

Administration: rinse the mouth after administration to prevent dry mouth, suck sugarless hard candy and sip fluids to control dry mouth

29

Methylxanthines Prototype: theophylline (Theo-24)

MOA: relaxes bronchial smooth muscle, resulting in bronchodilation

Therapeutic Uses: oral forms are used for long-term control of asthma or COPD (IV forms are used in emergencies only)

Complications: toxicity (GI distress, dysrhythmias, seizures), hyperglycemia, tachycardia

Contraindications/Precautions: heart disease, hypertension, liver/kidney disease, diabetes

Interactions: caffeine (no coffee, tea, energy drinks), fluroquinolone antibiotics increase levels, seizure drugs may decrease levels

Administration/Nursing Care: monitor serum drug levels (should be between 5-15mcg/mL, >20=toxicity), no smoking, IV administration should be done via pump with close monitoring

30

Inhaled Glucocorticoids Prototype: beclomethasone (QVAR)

MOA: prevent inflammation, suppress airway mucus production, promote responsiveness of beta2 receptors to bronchodilators

Therapeutic Use: does not provide immediate effects, promotes decreased frequency/severity of exacerbations/attacks-used for long-term prophylaxis of asthma

Complications: difficulty speaking, hoarseness, oral candidiasis

No significant contraindications, precautions, or interactions.

Administration: Use an MDI, DPI, or nebulizer on a regular, fixed schedule for long-term therapy. Not to be used for an acute episode. Albuterol should be taken first. Rinse the mouth and gargle after use and monitor for white patches on the tongue and oral mucosa.

31

Oral Glucocorticoids Prototype: prednisone (Deltasone)

MOA: prevent inflammation, suppress airway mucus production and edema, promote responsiveness of beta2 receptors

Therapeutic Use: short-term therapy to treat manifestations following an acute asthma episode. Long-term use to treat chronic, severe asthma.

Complications: adrenocortical insufficiency (not common with short term use), bone loss (use low dose or alternate day dosing), hyperglycemia, myopathy, PUD, infection, fluid/electrolyte disturbance, increased appetite, weight gain, insomnia, thin skin, hirsutism, menstrual irregularity, GI upset, hypertension

32

Oral Glucocorticoids Prototype: prednisone (Deltasone)

Contraindications/Precautions: those who have recently received a live virus vaccine and those who have systemic fungal infections, use cautiously in children and those with DM, hypertension, heart failure, PUD, osteoporosis, kidney dysfunction

Interactions: diuretics increase the risk of hypokalemia, NSAIDS increase the risk of PUD, glucocorticoids counteract the effects of oral hypolglycemics

Administration: take with food, use short-term (3-10 days) following acute exacerbation of asthma, while on long-term therapy additional doses may be required during times of stress, taper slowly after long term use.

33

Leukotriene Modifiers Prototype: montelukast (Singulair)

MOA: suppress the effect of leukotrienes thereby reducing inflammation, bronchoconstriction, airway edema, and mucus production

Therapeutic Use: long-term therapy of asthma in adults and children, can be used to prevent exercise-induced bronchospasm (2 hours prior to activity)

Complications: depression/suicidal ideation, headache, confusion, drowsiness, dizziness

Contraindications/Precautions: Use cautiously in patients with liver problems

Interactions: phenytoin may decrease the action of montelukast

Administration: Given orally once daily at bedtime, for exercise induced bronchospasm-take 2 hours before activity, replaces daily dose, granules can be mixed with soft foods (applesauce, ice cream, mashed potatoes)

34

Mast Cell Stabilizers Prototype: cromolyn (Intal)

MOA: inhibits the release of histamine and other inflammatory mediators from mast cells to prevent asthma attacks.

Therapeutic Use: long-term prophylaxis of asthma symptoms

Complications: postnasal drip, irritation of the nose/throat, cough (decreased by drinking water before and after the drug)

No significant contraindications/precautions/interactions.

Administration: oral inhalation, MDI, nebulizer, nasal spray. Rebound bronchospasm may occur-don’t discontinue abruptly. It has only moderate effectiveness and has a short half life requiring administration 4-6 times a day-steroids are preferable.

35

36

Administration of Pulmonary Drugs

Inhaled drugs are delivered via aerosol. This may be via nebulizer, metered dose inhaler (MDI), or dry powder inhaler (DPI).

Allows for delivery of drugs right where they need to act, leading to fewer complications/adverse effects.

Education on use of the device is required.

Spacers are recommended for patients of all ages (their use is more common in pediatrics) to help get the medication further into the pulmonary system.

Disadvantages: dose difficult to measure, only a small amount actually reaches lower respiratory tract, rinse mouth after use

37

Teaching Use of Inhalers-Pg. 6 ATI

MDI

Shake 5-6 times

Inhale deeply and exhale,

Place inhaler/spacer to mouth,

Activate the inhaler while taking a slow, deep breath,

Hold your breath for at least 10 seconds,

Exhale slowly through pursed lips,

Rinse mouth and spacer

Wait 5 minutes between different drugs.

Wait 1 minute in between puffs of same drug.

For DPI-do not shake, must activate per manufacturer’s guidelines

Bronchodilator should always be first.

Lifespan Consideration: Older Adults

Lifespan Consideration: Pediatrics

38

Nursing Process: Drugs for Respiratory Disorders

Assessment: medical/drug history, vital signs, respiratory assessment, hydration status

Diagnosis: dyspnea, airway obstruction, decreased gas exchange, fatigue

Planning: patient will be free from wheezing with clear lung fields in 2-5 days, will administer oral drugs and use inhaler as prescribed

Interventions/Teaching: monitor VS, provide hydration, watch for complications, monitor respiratory status, monitor drug levels (theophylline), teach MDI/DPI/nebulizer use, avoid smoking, wear a medical alert tag, report suicidal thoughts (montelukast), report more frequent use of rescue inhalers (albuterol)

Evaluation: free of wheezing, no complications, tolerates activity

39

References

McCuistion, L.E., DiMaggio, K.V., Winton, M.B, & Yeager, J.J. (2021). Pharmacology: A patient-centered nursing process approach. (10th ed.). St. Louis, MO: Elsevier.

Assessment Technologies Institute (2019). RN pharmacology for nursing (8th ed.). Stilwell, KS: ATI Publishing.

40