Respiratory Drugs - Chapter 37 PDF

Chapter 37 Respiratory Drugs By: Dr. Athena Watkins  Main Deliver function of oxygen to and remove the carbon dioxide from respiratory the cells of...

Chapter 37 Respiratory Drugs By: Dr. Athena Watkins  Main Deliver function of oxygen to and remove the carbon dioxide from respiratory the cells of the body system Upper respiratory tract (URT) Overvie w Lower respiratory tract (LRT) Alveoli: Point of gas exchange 2  Chronic obstructive pulmonary disease (COPD) Diseases Asthma (persistent and of the present most of the time Lower despite treatment) Emphysema Respirat Chronic bronchitis ory Tract 3  Recurrent and reversible shortness of breath Occurs when the airways of the lungs become narrow as a Bronch result of: ial Bronchospasms Inflammation of the Asthma bronchial mucosa Edema of the bronchial mucosa Production of viscous mucus 4  The alveolar ducts and alveoli remain open, but airflow to Bronch them is obstructed. ial Symptoms Asthma Wheezing (Cont.) Difficulty breathing 5  Asthma Four categories Intrinsic (occurring in patients with no history of allergies) Extrinsic (occurring in patients exposed to a known allergen) Exercise induced Drug induced 6 Asthma (Cont.) Status asthmaticus Prolonged asthma attack that does not respond to typical drug therapy May last several minutes to hours Medical emergency 7  Chronic Obstructive Pulmonary Disease (COPD) Chronic obstruction of Chronic lung airflow Not fully bronchitis & that interferes reversible emphysema with normal breathing 8  Chronic Bronchitis Continuous Excessive secretion of Often occurs as a inflammation and low- mucus and certain result of prolonged grade infection of the pathologic changes in exposure to bronchial bronchi the bronchial structure irritants 9  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 Emphyse ma The surface area where gas exchange takes place is reduced. Effective respiration is impaired. 10 Pharmacologic Overview 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 11  Short-acting beta agonist (SABA) inhalers Albuterol (Ventolin, ProAir) Bronchodilat Levalbuterol (Xopenex) ors: Beta- Terbutaline (Brethine) Adrenergic Agonists Metaproterenol (Alupent) SABAs are used as rescue inhalers for acute episodes 12  Bronchodilators: Beta- Adrenergic Agonists Long-acting beta agonist (LABA) inhalers *LABAs are never used for acute treatment! Arformoterol (Brovana) Formoterol (Foradil, Perforomist) Salmeterol (Serevent) 13  Used during acute phase of asthmatic attacks Bronchodilato Quickly reduce airway rs: Beta- constriction and Adrenergic restore normal airflow Agonists Agonists, or stimulators, of Sym the adrenergic path omi receptors in the meti sympathetic cs nervous system 14  Three types Nonselective adrenergics Stimulate alpha, beta1 (cardiac), and beta2 (respiratory) receptors Example: epinephrine (EpiPen) Bronchodilat Nonselective beta-adrenergics ors: Beta- Adrenergic Stimulate both beta1 and Agonists beta2 receptors (Cont.) Example: metaproterenol Selective beta2 drugs Stimulate only beta2 receptors Example: albuterol 15 Beta-Adrenergic Agonists: Mechanism of Action Begins at the specific Ends with dilation of receptor stimulated 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. 16  Relief of bronchospasm related to asthma, bronchitis, and other pulmonary Beta- diseases Adrener gic Used in treatment Agonists and prevention of acute attacks : Indicati ons Used in hypotension and shock 17  Alpha and beta (epinephrine) Insomnia Beta- Restlessness Adrener Anorexia gic Vascular headache Agonist Hyperglycemia s: Tremor Adverse Cardiac stimulation Effects 18  Long-acting beta2 agonist Beta- bronchodilator Adrener gic Never to be used for acute Agonists treatment : Used for the maintenance treatment of asthma and Salmete COPD and is used in conjunction with an inhaled rol corticosteroid (Sereve Salmeterol should never be nt) given more than twice daily nor should the maximum daily dose (one puff twice daily) be exceeded. 19  Acetylcholine (ACh) causes bronchial constriction and narrowing of the airways. Anticholinergics Anticholinergi bind to the ACh cs: receptors, Mechanism of preventing ACh Action from binding. Result: bronchoconstrictio n is prevented, airways dilate 20  Ipratropium (Atrovent), tiotropium (Spiriva), and aclidinium (Tudorza), others Indirectly cause airway relaxation and dilation Anticholinergi cs: Mechanism of Action (Cont.) Help reduce secretions in COPD patients Indications: prevention of the bronchospasm associated with chronic bronchitis or emphysema; not for the management of acute symptoms 21  Dry mouth or throat Nasal congestion Heart palpitations Anticholinergi cs: Adverse Gastrointestinal (GI) distress Effects Headache Coughing Anxiety 22  Cause bronchodilation by relaxing smooth muscle in the airways Result: relief of Xanthine bronchospasm and greater airflow into and out of the Derivativ lungs es: Drug Also cause central nervous system (CNS) stimulation 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) 23  Dilation of airways in asthmas, chronic bronchitis, and emphysema Mild to moderate cases of acute asthma Xanthine Derivativ NOT for management of acute es: asthma attack Indicatio Adjunct drug in the management ns of COPD Not used as frequently because of potential for drug interactions and variables related to drug levels in the blood 24  Nausea, vomiting, anorexia Gastroesophageal reflux during sleep Xanthine Derivativ Sinus tachycardia, es: extrasystole, palpitations, ventricular dysrhythmias Adverse Effects Transient increased urination Hyperglycemia 25  Used without prescription as a CNS stimulant or analeptic to promote alertness (e.g., for long-duration driving Xanthine Cardiac stimulant in or studying) Derivativ infants with bradycardia es: Caffeine Enhancement of respiratory drive in infants 26  Nonbronchodil ating Newer class of Leukotri asthma ene medications Receptor Antagoni Currently sts available drugs (LTRAs) Montelukast (Singulair) Zafirlukast (Accolate) Zileuton (Zyflo) 27  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. LTRAs: Mechani Result: coughing, wheezing, shortness sm of of breath Action 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. 28  By blocking leukotrienes: Prevent smooth muscle LTRA contraction of the bronchial airways s: Decrease mucus secretion Prevent vascular Drug permeability Decrease neutrophil and Effect leukocyte infiltration to the lungs, preventing Black Box warning s inflammation for montelukast Serious mood related changes and behaviours 29  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 LTRAs: Indicati Montelukast is also approved ons for treatment of allergic rhinitis Improvement with their use is typically seen in about 1 week. 30  Zileuton LTRAs : Headache, Adver nausea, se Zafirlukast dizziness, insomnia and Effect s montelukast Headache, nausea, diarrhea 31  Antiinflammatory properties Used for chronic asthma Do not relieve symptoms of Corticosteroid acute asthma attacks s (Glucocorticoi ds) May be administered IV Oral or Inhaled forms reduce systemic inhaled forms effects. May take several weeks before full effects are seen 32  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 Dual effect of both reducing inflammation and enhancing the activity of beta agonists 33  Inhaled Corticosteroids Beclomethasone dipropionate (Beclovent) Budesonide (Pulmicort Turbuhaler) Ciclesonide (Omnaris) Flunisolide (AeroBid) Fluticasone Flovent—inhaler Flonase--intranasal Mometasone (Asmanex) Triamcinolone acetonide (Azmacort) 34  Nursing Implications 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, and caffeine. 35  Nursing Implications (Cont.) 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 physicians before taking any other medication, including over-the-counter (OTC) medications. 36  Nursing Implications (Cont.) 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 Smoking history 37  Nursing Implications (Cont.) 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. 38  Which medication will the nurse teach a patient with asthma to use when Audien experiencing an acute asthma attack? ce Respon A. Albuterol se B. Salmeterol System C. Theophylline D. Montelukast Questio n #1 NOTE: No input is required to proceed. 39  Monitor for therapeutic effects: Decreased dyspnea Decreased wheezing, restlessness, and anxiety Nursing Improved respiratory patterns with return to Implicatio normal rate and quality ns Improved activity tolerance Decreased symptoms and increased ease of breathing 40  Albuterol, if used too frequently, loses its beta2-specific actions at larger doses & Nursing causes systemic Implicatio effects ns: As a result, beta1 Beta- receptors are Adrenergi stimulated, causing c Agonists nausea, increased anxiety, palpitations, tremors, and increased heart rate. 41  Audience Response System Question #2 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. The nurse should confirm the pharmacy location for the needed refill. B. The nurse should ask the patient to come to the office for an evaluation of his respiratory status. C. The nurse should tell the patient not to use this drug too often. D. The nurse should consult the prescriber for a different inhaler prescription. NOTE: No input is required to proceed. 42  Ensure that the drug is being used for chronic management of asthma, not acute asthma. Nursing Implicatio Teach the patient the ns: purpose of the LTRAs therapy. Improvement should be seen in about 1 week. 43  Teach patients to gargle and rinse the mouth with lukewarm water afterward to prevent the development of oral fungal infections. Nursing If a beta agonist Implication bronchodilator and s: corticosteroid inhaler are Inhaled both ordered, the Corticoster bronchodilator should be oids used several minutes before the corticosteroid to provide bronchodilation before administration of the corticosteroid. 44  Teach patients to monitor disease with a peak flow meter. Nursing Encourage use Implications of a spacer : device to ensure Inhaled successful Corticostero inhalations. ids (Cont.) Teach patient how to keep inhalers and nebulizer equipment clean after use. 45  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. 46 Audience Response System Question #3 A patient is prescribed two different types of inhaled medications for treatment of COPD. After administering the first medication, how long should the nurse wait to administer the second medication? A. 1 minute B. 5 minutes C. 10 minutes D. 15 minutes NOTE: No input is required to proceed. 47  Case Study The nurse is providing teaching to a group of individuals with COPD at a community center. 1. 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 immediately.” B. “I will inform my prescriber of any weight gain of 2 lb or more in 24 hours or 5 lb or more in 1 week.” C. “I use omalizumab to control my asthma but not for an acute asthma attack.” D. “When taking theophylline, I will advise my prescriber if I experience epigastric pain.” 48 NOTE: No input is required to proceed.  Case Study 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. 2. Which medication should the nurse inform the attendee to administer first for an acute asthma attack? A. Ipratropium B. Albuterol C. Budesonide D. Montelukast NOTE: No input is required to proceed. 49