CH 37: Respiratory Drugs – Flashcards
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Diseases of the Lower Respiratory Tract
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COPD -Asthma (persistent and present most of the time despite treatment) -Emphysema -Chronic bronchitis
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Bronchial Asthma
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-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 viscous mucus -Alveolar ducts/alveoli remain open, but airflow to them is obstructed -Symptoms Wheezing Difficulty breathing
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Asthma
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Four categories: 1. Intrinsic (occurring in patients with no history of allergies) 2. Extrinsic (occurring in patients exposed to a known allergen) 3. Exercise induced 4. Drug induced
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Asthma (cont'd)
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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
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-Continuous inflammation and low-grade infection of the bronchi -Excessive secretion of mucus and certain pathologic changes in the bronchial structure -Often occurs as a result of prolonged exposure to bronchial irritants
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Emphysema
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-Air spaces enlarge as a result of the destruction of alveolar walls -Caused by the effect of proteolytic enzymes released from leukocytes in response to alveolar inflammation -The surface area where gas exchange takes place is reduced -Effective respiration is impaired
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Pharmacologic Overview
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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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Bronchodilators: Beta-Adrenergic Agonists
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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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Bronchodilators: Beta-Adrenergic Agonists
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-Used during acute phase of asthmatic attacks -Quickly reduce airway constriction and restore normal airflow -Agonists, or stimulators, of the adrenergic receptors in the sympathetic nervous system -Sympathomimetics
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Bronchodilators: Beta-Adrenergic Agonists (cont'd): Three Types
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Three types 1. Nonselective adrenergics -Stimulate alpha, beta1 (cardiac), and beta2 (respiratory) receptors -Example: epinephrine 2. Nonselective beta-adrenergics Stimulate both beta1 and beta2 receptors Example: metaproterenol (Alupent) 3. Selective beta2 drugs Stimulate only beta2 receptors Example: albuterol (Proventil, others)
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Beta-Adrenergic Agonists: Mechanism of Action
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-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-Adrenergic Agonists: Indications
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-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-Adrenergic Agonists: Adverse Effects(Alpha and beta (epinephrine))
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-Alpha and beta (epinephrine) Insomnia Restlessness Anorexia Vascular headache Hyperglycemia Tremor Cardiac stimulation
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Beta-Adrenergic Agonists: Adverse Effects ( Beta1 and beta2 (metaproterenol))
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-Beta1 and beta2 (metaproterenol) Cardiac stimulation Tremor Anginal pain Vascular headache Hypotension
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Beta-Adrenergic Agonists: Adverse Effects ( Beta2 (albuterol))
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-Beta2 (albuterol) Hypotension OR hypertension Vascular headache Tremor
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Anticholinergics
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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
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-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- chewing on gum helps increase salivation. water by bed. Nasal congestion Heart palpitations Gastrointestinal distress Headache Coughing Anxiety- with tremor
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Xanthine Derivatives
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Plant alkaloids: caffeine, theobromine, and theophylline Only *theophylline* is used as a bronchodilator Synthetic xanthines: *aminophylline* and dyphilline
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Xanthine Derivatives: Mechanism of Action
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-Increase levels of energy-producing cAMP -This is done by competitively inhibiting phosphodiesterase (PDE), the enzyme that breaks down cAMP -Result: decreased cAMP levels, smooth muscle relaxation, bronchodilation, and increased airflow
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Xanthine Derivatives: Drug Effects
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-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 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: Indications
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-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
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-Nausea, vomiting, anorexia -Gastroesophageal reflux during sleep -Sinus tachycardia, extrasystole, palpitations, ventricular dysrhythmias -Transient increased urination -Hyperglycemia
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Leukotriene Receptor Antagonists (LTRAs)
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-Nonbronchodilating -Newer class of asthma medications -Currently available drugs: -montelukast (Singulair) -zafirlukast (Accolate) -zileuton (Zyflo)
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LTRAs: Mechanism of Action
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-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, shortnessof breath -LRTAs 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
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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
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-Prophylaxis and long-term treatment and prevention of asthma in adults and children 12 years of age and older -NOT meant for management of acute asthmatic attacks -Montelukast is also approved for treatment of allergic rhinitis
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LTRAs: Adverse Effects
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-zileuton -Headache, nausea, dizziness, insomnia, liver function -zafirlukast -Headache, nausea, diarrhea, liver function
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Corticosteroids
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-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 1-albuterol 2-broncho dilator 3-
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Corticosteroids: Mechanism of Action
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-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
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-*beclomethasone dipropionate (Beclovent)* -budesonide (Pulmicort Turbuhaler) -*dexamethasone sodium phosphate (Decadron Phosphate Respihaler)* -flunisolide (AeroBid) -*fluticasone (Flonase)* -triamcinolone acetonide (Azmacort) -ciclesonide (Omnaris) Sone-60% of the time is a steroid Flonase good for allergies
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Inhaled Corticosteroids:Indications
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Persistent asthma -Often used concurrently with beta-adrenergic agonists
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Inhaled Corticosteroids: Adverse Effects
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Pharyngeal irritation Coughing Dry mouth Oral fungal infections Systemic effects are rare because low doses are used for inhalation therapy
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Nursing Implications
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-Encourage patients to take measures that promote a generally good state of health so as to prevent, relieve, or decrease symptoms of COPD -Avoid exposure to conditions that precipitate bronchospasm (allergens, smoking, stress, air pollutants) -Adequate fluid intake -Compliance with medical treatment -Avoid excessive fatigue, heat, extremes in temperature, caffeine -Encourage patients to get prompt treatment for flu or other illnesses, and to get vaccinated against pneumonia or flu -Encourage patients to always check with their physician before taking any other medication, including over-the-counter medications
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Nursing Implications (cont'd)
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-Perform a thorough assessment before beginning therapy, including: Skin color Baseline vital signs Respirations (should be between 12 and 24 breaths/min) Respiratory assessment, including pulse oximetry Sputum production Allergies History of respiratory problems Other medications -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)
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-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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Which medication will the nurse teach a patient with asthma to use when experiencing an acute asthma attack?
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albuterol (Ventolin) Rationale: Albuterol (Ventolin) is a short-acting bronchodilator (SABA). Patients must be taught to use the SABAs as rescue treatment. Salmeterol (Serevent) is a long-acting bronchodilator. Because the LABAs have a longer onset of action, they must never be used for acute treatment . Because of their relatively slow onset of action, xanthines such as theophylline (Theo-Dur) are more often used for the prevention of asthmatic symptoms than for the relief of acute asthma attacks. Montelukast (Singulair) is an LTRA and is used primarily for oral prophylaxis and long-term treatment of asthma.
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Nursing Implications: Beta-Adrenergic Agonists
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-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 -Ensure that patients take medications exactly as prescribed, with no omissions or double doses -Inform patients to report insomnia, jitteriness, restlessness, palpitations, chest pain, or any change in symptoms
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A patient with chronic bronchitis calls the office for a refill of his albuterol inhaler. He just had the prescription filled 2 weeks ago, but he says it is empty. When asked, he tells the nurse, "I use it whenever I need it, but now when I use it I feel so sick. I've been needing to use it more often." What is the most appropriate action by the nurse?
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The nurse should ask the patient to come to the office for an evaluation of his respiratory status. Rationale: While it is true that the patient should be reminded about the correct use of this inhaler, it is evident that he has used it too often and that his respiratory status should be evaluated to see if an adjustment in the prescription should be made.
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Nursing Implications: Xanthine Derivatives
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-Contraindications: history of PUD or GI disorders -Cautious use: cardiac disease -Timed-release preparations should not be crushed or chewed (cause gastric irritation Report to prescriber: Nausea Vomiting Restlessness Insomnia Irritability Tremors
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Nursing Implications: Xanthine Derivatives (cont'd)
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-Be aware of drug interactions with cimetidine, oral contraceptives, allopurinol, certain antibiotics, influenza vaccine, others -Cigarette smoking enhances xanthine metabolism -Interacting foods include charcoal-broiled, high-protein, and low-carbohydrate foods -These foods may reduce serum levels of xanthines through various metabolic mechanisms
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Nursing Implications: LTRAs
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-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 -Advise patients to check with prescriber before taking over-the-counter or prescribed medications to determine drug interactions -Assess liver function before beginning therapy and throughout -Teach patient to take medications every night on a continuous schedule, even if symptoms improve
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Nursing Implications: Inhaled Corticosteroids
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-Teach patients to gargle and rinse the mouth with lukewarm water afterward to prevent the development of oral fungal infections -If a beta-agonist bronchodilator and corticosteroid inhaler are both ordered, the bronchodilator should be used several minutes before the corticosteroid to provide bronchodilation before administration of the corticosteroid -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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Inhalers: Patient Education
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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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A patient is prescribed two different types of inhaled medications for treatment of chronic obstructive pulmonary disease (COPD). After administering the first medication, how long should the nurse wait to administer the second medication?
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Five minutes Rationale: If a second puff of the same drug is ordered, instruct the patient to wait 1 to 2 minutes between puffs. If a second type of inhaled drug is ordered, instruct the patient wait 2 to 5 minutes between the medications or to take as prescribed. Bronchodilators are usually administered first.
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The nurse is providing teaching to a group of individuals with chronic obstructive pulmonary disease (COPD) at a community center. Which statement by one of the attendees indicates that further teaching is needed?
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"If I develop a puffy face, I will stop taking methylprednisolone (Medrol) immediately." Rationale: Patients should be taught to not stop systemic corticosteroids abruptly. The patient should be educated about the possibility of Addisonian crisis, which may occur if a systemic corticosteroid is abruptly discontinued. These drugs require weaning prior to discontinuation of the medication. Patients should monitor their weight daily and report the increase stated. Omalizumab (Xolair) is used for the treatment of moderate to severe asthma and not for aborting acute asthma attacks. Adverse effects of theophylline (Theo-Dur) that should be reported immediately to the prescriber include epigastric pain.
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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?
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albuterol (Proventil) Rationale: Albuterol (Proventil) is a short-acting beta2 agonist indicated for treatment of acute asthma attacks. Ipratropium (Atrovent) is an anticholinergic not indicated for treatment of acute asthma attacks. Budesonide (Pulmicort Turbuhaler) is an inhaled corticosteroid that should not be used in an acute asthma attack. Montelukast (Singulair) is a leukotriene receptor agonist used for long-term management of asthma, not for acute exacerbations.
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One of the attendees tells the nurse that he has asthma and is being treated with a short-acting inhaled beta2 agonist. The nurse identifies this treatment as which step of the stepwise therapy for the treatment of asthma?
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Step 1 Rationale: Step 1 includes use of a short-acting inhaled beta2 agonist as needed.
