chapter 37.docx

CHAPTER 37- Respiratory Drugs COPD: What is it? -Chronic Obstructive Pulmonary Disease is a disease of the LOWER respiratory tract. It’s an umbrella term for diseases such as Asthma, Emphysema, and Chronic Bronchitis. It is NOT FULLY REVERSIBLE. Bronchodilators- These drugs relax bronchial smooth mu...

CHAPTER 37- Respiratory Drugs COPD: What is it? -Chronic Obstructive Pulmonary Disease is a disease of the LOWER respiratory tract. It’s an umbrella term for diseases such as Asthma, Emphysema, and Chronic Bronchitis. It is NOT FULLY REVERSIBLE. Bronchodilators- These drugs relax bronchial smooth muscle, which causes dilation of the bronchi and bronchioles that are narrowed because of the disease process. There are three classes of bronchodilators. Beta-adrenergic agonists, anticholinergics, and xanthine derivatives. Status Asthmaticus- Prolonged asthma attack that DOES NOT respond to typical drug therapy. It may last several minutes to HOURS. This is a medical emergency, these patients need to go to the ER, because all other interventions did not work. SABA inhalers: Short-acting beta agonist – SABA’s are used as RESCUE inhalers for ACUTE episodes. Albuterol (Ventolin, ProAir) Levalbuterol (Xopenex) Terbutaline (Brethine) Metaproterenol (Alupent) LABA inhalers: Long-acting beta agonist *LABAs are never used for acute treatment! (these are made to be used for maintenance/prevention). Used for the maintenance treatment of asthma and COPD and is used in conjunction with an inhaled corticosteroid. Arformoterol (Brovana) Formoterol (Foradil, Perforomist) Salmeterol (Serevent) - should never be given more than twice daily nor should the maximum daily dose (one puff twice daily) be exceeded. Bronchodilators: Beta-ad agonists: Newest LABA Indacaterol (Arcapta Neohaler) Vilanterol in conjunction with fluticasone (breo Ellipta) Vilanterol in conjunction with the anticholinergic, umeclidinium (Anoro Ellipta) Advair inhaler (fluticas prop and salmeterol) Bronchodilators: Beta-Ad agonists- Are used during the acute phase of asthmatic attacks and quickly reduce airway constriction and restore normal airflow. These are agonists, or stimulators, of the adrenergic receptors in the sympathetic nervous system, also known as sympathomimetics. Their Mechanism of Action begins at the specific receptor that is stimulated and ends with dilation of the airways. Their Indications are Relief of bronchospasm related to asthma, bronchitis, and other pulmonary diseases. They are used in the treatment and prevention of acute attacks. Contraindications for these drugs are known drug allergy, uncontrolled hypertension, cardiac dysrhythmias, high risk of stroke (because of vasoconstrictive drug action). Three types of bronchodilators: Beta-Adrenergic Agonists (are sympathomimetics) Nonselective adrenergics- stimulate alpha, beta1 (cardiac) and beta2 (respiratory) receptors. An example of this would be Epinephrine (EpiPen) REMEMBER: EPI LOVES EVERYBODY. Adverse Effects of these medications include Insomnia, Restlessness, Anorexia, Vascular headache, Hyperglycemia, Tremor, and cardiac stimulation. **Keep in mind that if you give someone like epinephrine, you wouldn’t be concerned if they had like an increased heart rate or tremor because it is something to be expected. Nonselective beta-adrenergics- stimulate both beta1 and beta 2 receptors. An example of this would be Metaproterenol. Adverse effects of these medications would be: Cardiac stimulation, Tremors, Anginal pain, vascular headache, hypotension. Selective beta2 drugs- stimulate only beta2 receptors. An example of this would be albuterol. Adverse effects of these medications would be: Hypotension or hypertension, vascular headache, or tremors. The most common one with albuterol is tremors. Let the patient know that if albuterol is used too frequently, it loses its beta 2 soecific actions at larger doses and causes systemic effects. As a result beta receptos are stimulated, causing nausea, increased anxiety, palpitations, tremors and increased heart rate. So if a patient says “im feeling anxious” or “wow it feels like my heart is going to pop out of my chest” adv that this is to be expected w this medication *Increased systemic effects means multiple effects/reactions. Anticholinergics- Acetylcholine (ACh) causes bronchial constriction and narrowing of the airways. Anticholinergics bind to the ACh receptors, preventing ACh from binding. The result leads to bronchoconstriction being prevented, then the airways dilate. The patient is then able to breathe. Their Mechanism of action is to help reduce secretions in COPD patients and Indications are prevention of the bronchospasm associated with chronic bronchitis or emphysema; not for the management of acute symptoms. Adverse effects: Anticholinergics dry you out so you would have dry mouth, dry throat, coughing, anxiety, headache, heart palpitations, gastrointestinal distress, nasal congestion. Ipratropium (Atrovent)- is the oldest and most commonly used anticholinergic bronchodilator. It is available as a liquid aerosol for inhalation and as a multidose inhaler and usually dosed twice daily. Tiotropium (Spiriva) Aclidinium (Tudorza) Umeclidinium (Incruse Ellipta) Xanthine derivatives- Mechanism of action is they increase levels of energy-producing cAMP. This is done by completely inhibiting phosphodiesterase, the enzyme that breaks down cAMP. The result is decreased cAMP levels, smooth muscle relaxation, bronchodilation, and increased airflow. The Drug Effects for these cause bronchodilation by relaxing smooth muscle in the airways leading to relief of bronchospasm and greater airflow into and out of the lungs. They also cause CNS stimulation and cause cardiovascular stimulation by increasing the force of contraction and increased heart rate which results in resulting in increased cardiac output and increased blood flow to the kidneys (diuretic effects). Indications of these medications are dilation of airways in asthmas, chronic bronchitis and emphysema, mild to moderate cases of acute asthma. There are NOT for management of an acute asthma attack, 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. Theophylline: is ONLY used as a bronchodilator. It is the most commonly used xanthine derivative and is available oral, rectal, injectable (aminophylline) and topical dosage forms. The injectable Aminophylline is IV Intravenous treatment of patients with status asthmaticus who have no responded to fast acting beta agonists such as epinephrine. Therapeutic range is from 10-20 mcg/mL but most clinicians advise between 5-15 mcg/mL. Patient education- no caffeine when taking this as its derived from caffeine and may add to the side effects such as a headache, insomnia, and increases in blood pressure and heart rate. Nonbronchodilating respiratory drugs include Leukotriene receptor antagonists- Mechanism of action is that 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 mucous production. The result is coughing, wheezing, and shortness of breath. LTRAS (Leukotriene receptor antagonists) 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. Drug Effects are by blocking leukotrienes this prevents smooth muscle contraction of the bronchial airways and decreases mucous secretion, preventing vascular permeability and decreases neutrophil and leukocyte infiltration to the lungs thus preventing inflammation. Indications are prophylaxis and long-term treatment and prevention of asthma in adults and children 12 years of age and older. Not meant for management of of acute asthmatic attacks. Improvement is usually seen within one week. Contraindications include known drug allergy, previous adverse drug reaction, allergy to povidone, lactose, titanium dioxide, or cellulose derivatives is also important to note because there are inactive ingredients in these drugs. Montelukast (singulair) *BLACK BOX WARNING* Serious mood related changes and behaviors. Montelukast is also approved for treatment of allergic rhinitis. headache, nausea, diarrhea Zafirlukast (Accolate)-headache, nausea, dizziness, insomnia Zileuton (Zyflo)-headache, nausea, diarrhea Corticosteroids- are anti-inflammatory they decrease inflammation. DO NOT relieve symptoms of acute asthma attacks. Used for chronic asthma. May take several weeks before full effects are seen. Inhaled Corticosteroids – indications are the primary treatment of bronchospastic disorders to control the inflammatory responses that are believed to be the cause of these disorders, persistent asthma, often used concurrently with the beta-adrenergic agonists. Contraindications include drug allergy, not intended as a sole therapy for acute asthma attacks, hypersensitivity to glucocorticoids, patients whose sputum tests positive for candida organisms (like thrush, because it can make it worse)., patients with system fungal infection. Adverse effects are oral fungal infections. Drug interactions are more likely to occur with systemic (versus inhaled) corticosteroids. They may increase serum glucose levels, possibly requiring adjustments in dosages of antidiabetic drugs. Teach patients to gargle and rinse the mouth with lukewarm water afterward to prevent the development of oral fungal infections. Beclomethasone (Beclovent) Budesonide (Pulmicort Turbuhaler) Dexamethasone Flunisolide (Aerobid) Fluticasone Flovent-inhaler Flonase-intranasal Ciclesonide (Omnaris) Triamcinolone Acetonide (Azmacort) Mast cell stabilizers: rarely used cromolyn and nedocromil, which are sometimes used for exercise-induced asthma IV corticosteroids: are the only cortico steroids that can be used in acute exacerbation of asthma or other COPD Corticosteroids- are nonbronchodilating respiratory drugs. They act on leukotriene receptor and are antagonist.