Pharm Ch 37 Respiratory drugs – Flashcards
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COPD
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Asthma, Emphysema and Chronic Bronchitis; diseases of lower respiratory tract; all include obstruction of airways
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Asthma - Bronchial Asthma
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Recurrent & reversible shortness of breath; occurs when airways narrow from bronchospasms, inflammation or edema of bronchial mucosa, production of thick mucus; the aveolar ducts reman open but airflow is obstructed; SYMPTOMS: wheezing, difficulty breathing
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Asthma
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- Intrinsic - occuring in patients with no specific cause or history of allergies - Extrinisc - occuring in patients exposed to an allergin - Exercise induced - Drug induced body sees the drug as a foreign substance / antigen and attacks
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Asthma Status asthmaticus
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prolonged asthma attack that doesn't respond to typical drug therapy, may last several minutes to hours, is a medical EMERGENCY
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Chronic Bronchitis
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Continuous inflammation and low-grade infection of the bronchi; excessive mucus & pathologic chg in bronchial structures; often occurs as result of prolonged exposure to bronchial irritants (excessive smoking)
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Emphysema
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Air spaces enlarge as result of destruction of alveolar walls; caused by proteolytic enzymes released from leukocytes in ersponse to alveolar inflammation; surface area where gas exchange takes place is reduced and effective respiration is impaired
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Bronchodilators
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Relax bronchial smooth muscle, dilate bronchi and bronchioles that are narrowed from disease processes; 3 classes: beta-adrenergic agonists, anticholinergics, xanthine derivatives
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Bronchodilators - Beta Adrenergic Agonists
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Dialate the airways; USED FOR relief of bronchospasm related to asthma, COPD; used in prevention of acute asthma attacks, hypotension and shock, produce uterine relaxation to prevent premature labor - SHORT-ACTING BETA AGONIST (SABA) inhalers; used for acute asthma attacks; quickly reduce airway constriction & restore normal airflow; agonists/stimulators of adrenergic receptors in SNS (sympathomimetics); albuterol (Ventolin), levalburterol (Xopenex), pirbuterol (Maxair), terbutaline (Brethine), metaproterenol (Alupent) - LONG-ACTING BETA AGONIST (LABA) inhalers; for prevention; arformoterol (Brovana), formoterol (Foradil, Performist), salmeterol (Serevent) -NONSELECTIVE ADRENERGICS stimulate all receptors: alpha1, beta1 (cardiac) and beta2 (respiratory) EPINEPHRINE -NONSELECTIVE BETA ADRENERGICS stimulate both beta1 and beta2 receptors; metaproterenol (Alupent); -SELECTIVE BETA2 DRUGS stimulate only beta2 respiratory receptors ALBUTEROL; ACTIVATION OF BETA2 receptors activate CAMP, which relaxes smooth muscle in airway resulting in bronchial dilation and increased airflow; -ADVERSE EFFECTS insomnia, anorexia, headache, tremor, cardiac stimulation, hyper/hypotension, angina
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Anticholinergics
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Slow prolonged action USED TO PREVENT bronchoconstriction, NOT USED FOR ACUTE ASTHMA; prevents acetylcholine (ACh) from causing constriction & narrowing of airways by binding to ACh receptors; -ADVERSE EFFECTS dry mouth/throat, nasal congestion, heart palpitations, GI distress, headache, cough, anxiety - be careful peanut allergy; ipratropium bromide (Atrovent), tiotropium (Spiriva)
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Xanthine Derivatives
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-USED for dilation of airways in mild to moderate asthmas, chronic bronchitis, emphysema; adjunct drug for treatment of COPD, NOT USED FREQUENTLY because of potention for drug interactions - Increase levels of CAMP by inhibiting phosphodiesterase (PDE) from breaking CAMP down; causes smooth muscle relaxation, bronchodilation, increased airflow, relief of bronchospasm; CNS stimulation; cause cardiovascular stimulation: increased force of contraction & heart rate, increased cardiac output & blood flow to kidneys (diuretic effect); plant alkaloids caffein, theobromine, theophylline (bronchodilator), synthetics: aminophylline, dyphilline; -ADVERSE EFFECTS nausea, anorexia, GI reflux, tachycardia & dysrhythmias, increased urination, hyperglycemia -CONTRAINDICATED in history of PUD or GI disorders; be cautious in cases of cardiac disease; -INTERACTIONS cimetidine, oral contraceptives, antibiotics, flu vaccine; interacts with charcoal broiled, high protein, and low carb foods, can reduce xanthines blood levels -AVOID CIGARETTE SMOKING it enhances xanthine metabolism
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LTRAs
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-nonbronchodilating, limited action to the lungs; prevent smooth muscle contraction of airways, decrease mucus; WORK by preventing leukotrienes from attaching and causing cough, wheezing, SOB; PREVENT ASTHMA SYMPTOMS (cough, wheezing, SOB) for profilactic longterm treatment; NOT USED FOR ACUTE ASTHMA; montelukast, singulair also approved to treat allergic rhinitis, zileuton, zafirlukast; ADVERSE EFFECTS HEADACHE, nausea, dizzi, diarrhea, LIVER FUNCTION
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Corticosteroids
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-antiinflammatory, prevent release of leukocytes that cause bronchoconstriction; also increase response to betaadrenergics and commonly used as adjuct with them; -USED FOR chronic asthma NOT ACUTE ASTHMA; oral and inhaled forms; may take several weeks before full effects are seen; -INHALED FORMS REDUCE systemic effects such as weight gain, affect on glucose -Oral forms cause oral fungus infection -ADVERSE EFFECTS pharyngeal irritation, cough, dry mouth, oral fungus infections, systemic effects rare because low doses used for inhalation therapy; -MUST BE taken off gradually to prevent death from Addisonian crisis; also can suppress bone growth in children prednisone, beclomethasone dipropionate (Beclovent), budesonide (Pulmicort Turbuhaler), dexamethasone sodium phosphate (Decadron), flunisolide (Aerobid), Fluticasone (Flonase), triamcinolone (Azmacort), ciclesonide (Omnaris)
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Phosphodiesterase-4 Inhibitor
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roflumilast (Daliresp); USED to prevent cough and excess mucus from worsening COPD symptoms; ADVERSE nausea, headache, insomnia, weight loss, psychiatric symptoms
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Monoclonial Antibody Antiaasthmatic
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omalizumab (Xolair); selectively binds to immunoglobulin IgE, limiting release of mediators of allergic response; given by injection only, can produce anaphylaxis; closely monitor for hypersensitivity
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TEACHING
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-avoid exposure to allergens, smoking, stress, air polutants; adequate fluid intake; comply w/medical treatment; avoid excessive fatigue, heat, extremes in temperature, caffeine; get prompt treatment for flu / illness; get vaccinated against pneumonia and flu; take bronchodilators exactly as prescribed, know how to use the inhalers and MDI's -make sure patients report any symptoms of insomnia, jitteriness, restlessness, palpitations, chest pain
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NOTES
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-albuterol can lose it's beta2 specific actions at larger doses or if used too often, causing beta1 receptors to be stimulated instead causing nausea, anxiety, palpitations, tremors, increased heart rate PATIENTS MUST REPORT THESE SYMPTOMS -Xanthines are contraindicated in history of PUD or GI disorders; be cautious in cases of cardiac disease; -LTRA's constantly assess liver function, before beginning therapy and throughout; gargle and rinse mouth with lukewarm water after taking to prevent oral fungal infections -USE BRONCHODILATORS FIRST to allow bronchodilation before admin of corticosteroids -patients should monitor their disease with a peak flow meter -encourage use of spacer to insure successful inhalations and keep all inhalers and nebulizer equipment clean!
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z Which medication will the nurse teach a patient with asthma to use when experiencing an acute asthma attack? A) albuterol (Ventolin) B) salmeterol (Serevent) C) theophylline (Theo-Dur) D) montelukast (Singulair)
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Correct answer: A 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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z 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? A) RN should confirm the pharmacy location for the needed refill. B) RN should ask the patient to come to the office for an evaluation of his respiratory status. C) RN should tell the patient not to use this drug too often. D) RN should consult the prescriber for a different inhaler prescription.
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Correct answer: B 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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z 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? A) One minute B) Five minutes C) Ten minutes D) Fifteen minutes
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Correct answer: B 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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z 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? A) "If I develop a puffy face, I will stop taking methylprednisolone (Medrol) immediately." B) "I will inform my prescriber of any weight gain of 2 pounds or more in 24 hours or 5 pounds or more in 1 week." C) "I use omalizumab (Xolair) to control my asthma but not for an acute asthma attack." D) "When taking theophylline (Theo-Dur), I will advise my prescriber if I experience epigastric pain."
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Correct answer: A 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.
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z 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? A) ipratropium (Atrovent) B) albuterol (Proventil) C) budesonide (Pulmicort Turbuhaler) D) montelukast (Singulair)
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Correct answer: B Albuterol (Proventil) is a short-acting beta2 agonist indicated for treatment of acute asthma attacks. All others listed are for long-term or profilactic treatment.
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z 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? A) Step 1 B) Step 2 C) Step 3 D) Step 4
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Correct answer: A Step 1 includes use of a short-acting inhaled beta2 agonist as needed.
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z A patient who has a history of asthma is experiencing an acute episode of shortness of breath and needs to take a medication for immediate relief. The nurse will choose which medication that is appropriate for this situation? A) A beta agonist, such as albuterol B) An leukotriene receptor antagonist, such as montelukast C) A corticosteroid, such as fluticasone D) An anticholinergic, such as ipratropium
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A
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z After a nebulizer treatment with the beta agonist albuterol, the patient complains of feeling a little "shaky," with slight tremors of the hands. The patient's heart rate is 98 beats/min, increased from the pretreatment rate of 88 beats/min. The nurse knows that this reaction is an A) expected adverse effect of the medication. B) allergic reaction to the medication. C) indication that he has received an overdose of the medication. D) idiosyncratic reaction to the medication.
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A
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z A patient has been receiving an aminophylline (xanthine derivative) infusion for 24 hours. The nurse will assess for which adverse effect when assessing the patient during the infusion? A) CNS depression B) Sinus tachycardia C) Increased appetite D) Temporary urinary retention
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B
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z During a teaching session for a patient who will be receiving a new prescription for the LTRA montelukast (Singulair), the nurse will tell the patient that the drug has which therapeutic effect? A) Improves the respiratory drive B) Loosens and removes thickened secretions C) Reduces inflammation in the airway D) Stimulates immediate bronchodilation
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C
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z After the patient takes a dose of an inhaled corticosteroid, such as fluticasone (Flovent), what is the most important action the patient needs to do next? A) Hold the breath for 60 seconds. B) Rinse out the mouth with water. C) Follow the corticosteroid with a bronchodilator inhaler, if ordered. D) Repeat the dose in 15 minutes if the patient feels short of breath.
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B
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z The nurse is teaching a patient about the inhaler Advair (salmeterol/fluticasone). Which statements by the patient indicate a correct understanding of this medication? Select all that apply. A) "I will rinse my mouth with water after each dose." B) "I need to use this inhaler whenever I feel short of breath, but not less than 4 hours between doses." C) "This medication is taken twice a day, every 12 hours." D) "I can take this inhaler if I get short of breath while exercising." E) "I will call my doctor if I notice white patches inside my mouth."
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A, C, E
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z A patient has been given an MDI of albuterol and is instructed to take two puffs three times a day, with doses 6 hours apart. The inhaler contains 200 actuations, but does not have a dose counter. Calculate how many days the inhaler will deliver this ordered dose.
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33 days (6 puffs per day divided into 200 puffs)
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z A patient is taking a xanthine derivative and asks the nurse about drinking coffee with the medication. What is the nurse's best answer?
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Consumption of anything containing caffeine increases or exacerbates the (CNS) stimulation associated with the xanthine-derived medications. Overstimulation of the CNS may have a severe impact on the patient and could be life threatening. In addition, these products may cause increased HR. These products should be avoided while on the xanthine derivative. This is especially important for pts with history of cardiac problems, such as angina or sinus tachycardia/other rapid-rate dysrhythmias.
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z A patient was prescribed an oral leukotriene receptor antagonist (LRTA) 1 month ago. At today's follow-up appointment, he tells the nurse, "I don't think this pill works. I took it when I was short of breath, but it did not help." What is the priority when the nurse answers this patient's concerns?
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A patient has to understand that LRTAs are used for prophylaxis in asthmatic attacks when taken on a long-term basis. They are not used to treat acute attacks. Tell patient the medication must be taken regularly for best effects, even if the symptoms improve and the patient is feeling better. In addition, it takes several weeks for full therapeutic effects to occur. In addition, the nurse needs to review with the patient which medications are indicated for acute asthma attacks.
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z A 13-year-old is taken to the school clinic because he started to have an asthma attack while running outside in the cold air. The school nurse has two metered-dose inhalers on file for him: fluticasone and albuterol. Which inhaler is the priority at this time?
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The appropriate inhaler is the albuterol inhaler because it is a rapid-acting bronchodilator. Fluticasone is an inhaled corticosteroid and is used for prevention of asthma attacks, but it does not cause bronchodilation. It is not appropriate for use as a rescue inhaler.
