Cardiorespiratory: Analgesics

• Pharmacology knowledge from undergraduate studies is assumed for physiology knowledge
• Common medications relevant to cardiorespiratory physiotherapy are reviwed
• Understanding how drugs are used, not how they act, is the goal
• The notes section of the medication tables includes physiotherapy-specific considerations

Analgesics

• Analgesics are drugs that relieve pain, with different medications used for different pain types based on severity and cause

Narcotics

• Pethidine is an example product name, Methadone is the example generic name
• Fentanyl is an example product name, Oxycodone is the example generic name
• Morphine, Omnopon, Physeptone, Endone, and MS Contin are product names, Morphine is the example generic name
• Narcotics can cause constipation, posing a challenge for long-term hospital clients

Simple Analgesics

• Panadol and Solprin are the product names, Paracetamol and Asprin are the generic names
• No prescription is needed, but physiotherapists can not recommend their usage

Local Analgesics

• Marcain and Lignocaine are example product names, Bupivacaine and Lignocaine are example generic names
• Local analgesics prevent sensation only in the application area

Anti-Inflammatory Drugs

• Anti-inflammatory drugs reduce inflammation and can alleviate pain when inflammation contributes

Non-Steroidal Anti-Inflammatories (NSAIDs)

• Naprosyn, Feldene, Brufen, and Voltaren are the product names, Naproxen, Piroxicam, Ibuprofen, and Diclofenac are generic names
• NSAIDs are not safe for pregnant individuals

Steroidal Anti-Inflammatories (SAIDs)

• Hydrocortisone, Dexmethsone, Depo-medrol, Prednisone/Prednisolone are product examples, Hydrocortisone, Dexamethasone, and Methylprednisolone are generic examples
• Prolonged corticosteroid use can induce glucocorticoid-induced osteoporosis, steroid-induced myopathy, and cushingoid features like fat redistribution, truncal obesity, buffalo hump, moon face, and weight gain

H2 Receptor Antagonists

• H2 Receptor Antagonists reduce stomach acid production, treating gastric ulcers and conditions with excessive stomach acid

H2 Receptor Antagonist Examples

• Tagamet, Zantac, and Pepcidine/Pepcid are product names, Cimetidine, Ranitidine, and Famotidine are generic names
• These may appear in a client’s medical chart

Anti-Emetics

• Anti-emetics prevent nausea and vomiting, with "emetic" meaning 'causing vomiting'

Anti-Emetic Examples

• Maxalon, Stemetil, and Zofran are product names, Metoclopramide, Prochlorperazine, and Ondansetron are generic names
• Maxalon and Stemetil can be taken via injection or orally
• Zofran is commonly taken sublingually or buccally

Proton Pump Inhibitors

• Proton pump inhibitors treat heartburn and acid-related disorders like GORD
• GORD can scar and narrow the esophagus

Proton Pump Inhibitors Examples

• Losec and Zoton are product names, Omeprazole and Iansoprazole are generic names
• These may be listed in a client's medical chart

Respiratory Medications

• Respiratory medications require a good understanding for physiotherapy interventions

β2 Agonists

• Ventolin and Bricanyl are short-acting β2 agonists, Salbutamol and Terbutaline are generic names
• Serevent & Oxis/Foradile are long-acting β2 agonists, Salmeterol & Eformoterol are generic names
• Act to encourage bronchodilation, and relieve asthma attacks
• Asthma reliever medication is typically found in a blue puffer

Inhaled Corticosteroids

• Var, Pulmicort, and Flixotide are product names, Beclomethasone, Budesonide, and Fluticasone are generic names
• Used for asthma attack prevention as they suppress inflammation
• Asthma preventer medication puffers are not commonly blue

Anticholinergics

• Atrovent and Spiriva are product names, Ipratropium Bromide and Tiatropium are generic names
• Block the parasympathetic nervous system, function to dilate the bronchi and relieve shortness of breath
• Prescribed to aid respiratory disorders (asthma, COPD)

Combination Medications

• Combivent and Seretide are product names
• Combivent consists of Atrovent + salbutamol
• Seretide consists of Flixotide + serevent
• These achieve the effect of both medications

Mucolytics

• Mucomyst and Pulmozyme are example product names, Dornase alpha is the example generic narme
• Used to break up secretions for easier mobilization and removal

Diabetes Mellitus Types

• Type 1 Diabetes Mellitus (T1DM) is Insulin Dependent Diabetes Mellitus (IDDM)
• Type 2 Diabetes Mellitus (T2DM) is Non-Insulin Dependent Diabetes Mellitus (NIDDM)
• NIDDM involves reduced tissue sensitivity to insulin, while IDDM involves insufficient insulin production from pancreatic cells
• Actrapid and Monotard are IDDM examples, Chlorpropamide and Metformin are NIDDM examples
• Diaformin is an example of an oral hypoglycemic

Cardiovascular Medications

• Cardiovascular medication targets heart disease

Diuretics

• Lasix and Demadex are example product names, Frusemide and Torsemide are generic names
• They help the body remove water and salt which in turn aids in reducing swelling in the body

Nitrates

• Anginine, Transiderm, and Isordil are example product names- Isosorbide dinitrate is the example generic name
• Dilate veins and arteries– improving blood flow to the heart, and decreasing angina

Calcium Channel Blockers

• Isopten, Cardizem, and Adalet are product names, Verapamil, Diltiazem and Nifedipine are generic names
• Aid in reducing blood pressure

ACE Inhibitors

• Capoten and Renitec are product names, Eaptopril and Enalapril are generic names
• Help to reduce vein and artery pressure

Beta Blockers

• Inderal Betaloc/lopressor and Tenormin are product names, Propranolol, Metoprolol, and Atenolol are generic names
• Reduce BP by blocking

Angiotensin II Receptor Antagonist

• Avapro is an example product name, Irbesartan is the example generic name

Notes on Adrenaline and Noradrenaline

• Adrenaline = epinephrine
• Noradrenaline = norepinephrine
• The generic term 'adrenaline' is patented in some countries

Antibiotics

• Antibiotics treat infections, with varying types effective against different infections
• Antibiotic-resistant infections are a significant research area

Penicillins

• Amoxycilline and Flucloxicillin are product names, Amoxil/Moxacin is the generic name
• Most effective on gram-positive bacteria, treat pneumonia

Cephalosporins

• Keflex and Rocephin are product names, Cephalexin and Ceftriaxone are generic names
• Manage a range of gram-positive and gram-negative bacteria infections as well as soft tissue infections

Tetracyclines

• Vibramycin is a product name, Doxycycline is the generic name
• Only effective against multiplying microorganisms

Aminoglycosides

• Gentamicin and Tobramycin are generic names
• Act as broad-spectrum antibiotics, inhibit protein synthesis

Anti-Fungal

• Flagyl is the product name, Metronidazole is the generic name
• Can treat varying conditions, from athlete's foot to meningitis

Sedatives

• Sedatives are drugs that sedate and calm

Sedative Examples

• Normison, Rohypnol, Mogadon, Diazepam, Valium, Diprivan, and Midazolam are product names, Temazepam, Flunitrazepam, Nitrazepam, Propofol, and Ketamine are generic names
• Note if clients received sedatives during their hospital stay to understand client status

Anti-Coagulants

• Anti-coagulants act as blood thinners to prevent clots

Anti-Coagulant Examples

• Heparin, Warfarin, and Clexane are product names
• They are often indicated if client has a history of hypertension as they work to reduce the risk of clotting

Medication in Surgery

• Understanding medications relevant to surgical intervention is important for physiotherapists to influence assessment and management

General Anesthetics

• Provide unconsciousness, amnesia, and analgesia suitable for major abdominal and thoracic surgery

Post-operative Analgesia

• Routes of drug administration can vary

Oral Route

• Slow acting
• Absorbed by small intestine (requires a working gut)
• Paracetamol, NSAIDs, and Codeine are examples

Intramuscular (IM) Route

• Maximum blood concentration in 15-60 minutes
• Absorption is variable
• Only provides adequate analgesia for 35% of the 4 hours
• May be painful and therefore rarely used
• Example drugs: Morphine, Pethidine, and Tramadol

Subcutaneous (SC) Route

• Maximum blood concentration in 15-60 minutes
• Absorption is less variable
• Less painful
• Example drugs: Morphine and Pethidine

Intravenous (IV) Infusion Route

• More rapid action onset
• Lower continuous infusion eliminates peaks and troughs
• Loading bolus needed for analgesic blood concentration
• High respiratory depression risk with continuous IV opioids
• Example drugs: Morphine, Fentanyl, Ketamine, and Oxycodone

Patient-Controlled Analgesia (PCA) Route

• Client self-administers small doses of IV analgesics upon experiencing pain
• Microprocessor pumps deliver pre-set bolus doses, subject to a ‘lock-out interval’
• Offers client autonomy, eliminates delivery delays and reduces total narcotic dose, but may not work for some or there may be improper programming
• Example drugs: Morphine, Fentanyl, and Oxycodone

Epidural Route

• Fine-bore catheter inserted into thoracic or lumbar epidural space by anesthetist during operation
• Pump continuously infuses drugs via a bacterial filter, blocking nerves from the spinal cord
• May be combined with client-controlled system (PECA- for smaller cumulative doses vs continuous infusion)
• Side effects may include hypotension, respiratory depression, total spinal block causing motor and sensory block, nausea/vomiting, urinary retention, headache, and neck stiffness
• Example drugs: Fentanyl, Bupivacaine, Ropivacaine, Morphine, and Adjuvants (such as clonidine)

Peripheral Blocks

• Provides benefit of having less central side effects compared to other methods
• Involves direct injection of local anesthetics into the main nerve for the operative area or incision
• Most effective for incisional pains rather than visceral
• Example drugs: Bupivacaine and Ropivacaine

Intercostal Nerve Blocks

• Used for limited incisions to thoracic dermatomes, offers effective relief for incisional pain (not visceral)

Intrapleural Analgesia

• Catheter placed intrapleurally & local anesthetic administered for unilateral pain relief
• Best for surgery with intact pleura
• Not commonly used

Physiotherapist's Role in Medication Management

• Understanding the indication, and function of the drugs is crucial

Scenarios

• Understanding side effects is crucial in outpatient respiratory clinics to understand client progress
• In oncology, understanding chemotherapy patterns helps the exercise selection
• It is not the physiotherapist's role to make recommendations to client regarding medication
• Physiotherapists can approach doctors and nurses with client medication needs such as a changing medication or oxygen saturation level

Asthma

• A reliever, such as a "blue puffer", does not prevent future asthma exacerbations
• Providing education and encouraging adherence to the prescribed medication regimen are the role of the physiotherapist