LOWER RESPIRATORY Pulmonary Disease PDF

# Drugs Acting on the Respiratory Tract ## Outline: - Drugs Acting on the Respiratory Tract - Drugs Acting on the Lower Respiratory Tract - Learning Objectives - Key Terms - Manifestations of COPD - Changes in The Airway with COPD - Adult Respiratory Distress Syndrome (ARDS) - Bronchodilators/Anti...

# Drugs Acting on the Respiratory Tract ## Outline: - Drugs Acting on the Respiratory Tract - Drugs Acting on the Lower Respiratory Tract - Learning Objectives - Key Terms - Manifestations of COPD - Changes in The Airway with COPD - Adult Respiratory Distress Syndrome (ARDS) - Bronchodilators/Anti-asthmatics - Xanthines - BOX 55.3 Enzyme Therapy: Alpha1-Protease Inhibitor (Human) - Sympathomimetics - Anticholinergics - Inhaled Steroids - Prototype Inhaled Steroids (Pulmicort) - Management of Chronic Asthma in Adults - Nursing Considerations for Xanthines - Prototype Xanthines - Prototype Sympathomimetics - Prototype Anticholinergics - Prototype Summary: Ipratropium ## Figure Descriptions - An illustration of the respiratory system. - An illustration of the lower respiratory system. - An illustration of the effects of drugs on an airway. ## Learning Objectives: 1. Define pharmacology Key terms. 2. Describe the underlying pathophysiology involved in obstructive pulmonary disease and correlate this information with the presenting signs and symptoms. 3. Describe the therapeutic actions, indications, pharmacokinetics, contraindications, most common adverse reactions, and important drug-drug interactions associated with drugs used to treat lower respiratory tract disorders. 4. Discuss the use of drugs used to treat obstructive pulmonary disorders across the lifespan. 5. Compare and contrast the prototype drugs used to treat obstructive pulmonary disorders with other agents in their class and with other classes of drugs used to treat obstructive pulmonary disorders. 6. Outline the nursing considerations, including important teaching points, for patients receiving drugs used to treat obstructive pulmonary disorders. # Key Terms: | Term | Arabic | Description | |---|---|---| | Asthma | الكراش | A condition in which your airways narrow and swell, making it hard to breathe. | | Bronchoconstriction | ممر ضيق | The narrowing of the airways in the lungs. | | Atelectasis | Collapse of lung | A complete or partial collapse of a lung. | | Bronchodilator | موسع | Any drug that opens up the airways in the lungs. | | Cheyne-Stokes | Abnormal respiration | An abnormal pattern of breathing characterized by periods of shallow or absent breathing followed by periods of rapid, deep breathing. | | Chronic Obstructive Pulmonary Disease (COPD) | Abnormal respiration | A group of lung diseases that cause airflow blockage and breathing problems. | | Cystic Fibrosis | تحصل معاها | A genetic disorder that affects the lungs, digestive system, and other organs. | | Leukotriene Receptor Antagonists | Cinflammatory mediators | Drugs that block the effects of leukotrienes, which are inflammatory chemicals that contribute to asthma. | | Mast Cell Stabilizer | | Drugs that stop mast cells from releasing histamine and other chemicals that cause inflammation. | | Pneumonia | ✓✓ | An infection of the lungs that causes inflammation of the air sacs in the lungs. | | Pneumothorax | Arnto space bet. chest wall | A collapsed lung, or a lung that has partially collapsed. | | Respiratory Distress Syndrome (RDS): asthma | | A respiratory condition that causes difficulty breathing, especially in infants. | | Sympathomimetics | | Drugs that mimic the effects of the sympathetic nervous system. | | Xanthenes | | A class of drugs that relax smooth muscle, including the smooth muscle in the airways. | # Manifestations of COPD: - Air is trapped in the lower respiratory tract - The alveoli degenerate and fuse together. - The exchange of gases is greatly impaired. ## Prevention and Treatment for COPD: - Reduce environmental exposure to irritants. - Smoking cessation - Filter allergens from the air. - Avoid exposure to known irritants and allergens. - Open the conducting airways through muscular bronchodilation. - Decrease the effects of inflammation on the airway lining # Changes in the Airway With COPD: - Panlobular emphysema (PLE) - Centrilobular emphysema (CLE) # Adult Respiratory Distress Syndrome (ARDS): - **Characteristics:** - Progressive loss of lung compliance and increasing hypoxia. - **Causes:** - Cardiovascular collapse - Major burns - Severe trauma. - Rapid depressurization/drop in pressure - **Treatment:** - Reversal of the underlying cause combined with ventilatory support # Bronchodilators/Anti-asthmatics: - Used to facilitate respiration by dilating the airways. - Xanthines - Sympathomimetics - Anticholinergics - A new type of drug used to treat alphal-protease deficiency, Zemaira # Xanthines: - Caffeine (Caffedrine, and others) - **Theophylline (generic)** - **Actions:** - Direct effect on the smooth muscles of the respiratory tract, both in the bronchi and in the blood vessels. - **Indications** - **Asthmas** - Prophylaxis - Symptomatic relief or prevention of bronchial asthma and for reversal of bronchospasm associated with COPD. - **Pharmacokinetics:** - Rapidly absorbed for the GI tract. - Metabolized in the liver and excreted in the urine. - **Contraindications:** - GI problems, coronary disease, respiratory dysfunction, renal or hepatic disease, alcoholism, or hyperthyroidism. - **Adverse Effects:** - Related to theophylline levels in the blood (levels are from 10 to 20 mcg/mL). - GI upset, nausea, irritability, and tachycardia to seizure, brain damage, and even death. - **Drug-Drug Interactions:** - Many drugs interact with xanthines. - Substances in cigarettes (Nicotine increases the metabolism of xanthines in the liver). # Sympathomimetics: - **Actions:** - (Beta, selective adrenergic agonists) ✗ - **Indications:** - Acute asthma attach - Bronchospasm in acute or chronic asthma. - Prevention of exercise-induced asthma (Prophylaxis) - **Pharmacokinetics:** - Rapidly distributed after injection, transformed in the liver to metabolites that are excreted in the urine. - **Contraindications:** - Depends on the severity of the underlying condition - **Adverse Effects:** - Sympathomimetic stimulation - CNS stimulation - GI upset, cardiac arrhythmias, hypertension, bronchospasm, sweating, pallor, and flushing. - **Drug-Drug Interactions:** - General anesthetics - **Nursing Considerations:** - History and Physical Exam and known allergy - Cigarette use, pregnancy and lactation - Hyperthyroidism - Cardiac disease, vascular disease, arrhythmias, diabetes, and reflexes - Reflexes and orientation, VS, reflexes and orientation and appropriate lab values # Anticholinergics: - **Patients who cannot tolerate the sympathetic effects of the sympathomimetic might respond to the anticholinergic drugs.** - **Actions:** - Anticholinergic that blocks vagally mediated reflexes by antagonizing the action of acetylcholine. - **Indications:** - Maintenance treatment of bronchospasm associated with COPD. - **Pharmacokinetics:** - Onset of action is 15 minutes when inhaled. - Peaks in 1-2 hours, duration of action is 3-4 hours. - **Caution:** - Any condition that would be aggravated by the anticholinergic effects of the drug. - **Adverse Effects:** - Related to the anticholinergic effects of the drug - Dizziness, headache, fatigue, nervousness, dry mouth, sore throat, palpitations, and urinary retention. - **Drug-Drug Interactions:** - Other anticholinergics - **Nursing Considerations:** - History and Physical Exam and known allergy. - Acute bronchospasm, bladder neck obstruction or prostatic hypertrophy, orientation, affect, and reflexes. - Pulse and B/P, respirations and adventitious sounds and urinary output # Inhaled Steroids: - Very effective treatment for bronchospasm. - **Actions:** - Decrease the inflammatory response in the airway. - **Indications:** - Prevention and treatment of asthma - Treat chronic steroid-dependent bronchial asthma - **Pharmacokinetics** - Well absorbed from the respiratory tract. - Metabolized by natural systems, mostly within the liver, excreted in the urine. - **Contraindications:** - Not used for emergency during an acute attack of status asthmaticus - Pregnancy or lactation - **Adverse Effects:** - Sore throat - Hoarseness - Coughing - Dry mouth - Pharyngeal and laryngeal fungal infections - **Nursing Considerations:** - History and Physical Exam and known allergy. - Systemic infections, pregnancy and lactation - VS, respirations, adventitious sounds, nares # Prototype Inhaled Steroids (Pulmicort) - **Indications:** - Prevention and treatment of asthma: - to treat chronic steroid-dependent bronchial asthma: - as adjunct therapy for patients whose asthma is not controlled by traditional bronchodilators - **Actions:** - Decreases the inflammatory response in the airway; this action will increase airflow and facilitate respiration in an airway narrowed by inflammation. - **Pharmacokinetics:** - **Route** - Inhalation - **Onset** - Slow - **Peak** - Rapid - **Duration** - 8-12 h - **T1/2:** 2 to 3 hours; metabolized in the liver and excreted in the urine. - **Adverse Effects:** - Irritability, headache, rebound congestion, local infection # Management of Chronic Asthma in Adults - **Modified from British Thoracic Society Guidance 2016.** - There should be started at step 1 and worked upwards until control of symptoms is achieved. Once symptoms have been controlled it may be possible to step down - **Step 1 (Reliever therapy):** Inhaled short-acting ß2 agonist (SABA) - **Step 2 (Preventer therapy):** Inhaled SABA plus low dose inhaled corticosteroid - **Step 3:** Add in inhaled long-acting ß2 agonist (LABA) to low-dose inhaled corticosteroid (usually combination inhaler) - **Step 4:** - No response to LABA: stop LABA and consider increased dose of inhaled corticosteroid - If benefit from LABA but control still inadequate: continue LABA and increase inhaled corticosteroid to moderate dose - If benefit from LABA but control still inadequate: continue LABA and inhaled corticosteroid and consider trial of other therapy (theophylline or long-acting muscarinic antagonist e.g., Ipratropium) - Consider trials of: - Increasing inhaled corticosteroid to high dose - Addition of fourth drug - Refer to specialist care - **Step 5:** Use daily steroid tablet in the lowest dose to provide adequate control - **Step 6:** - Maintain high dose inhaled corticosteroid - Refer to specialist care - **Stepping down:** If control is achieved, stepwise reduction in therapy may be possible. # Nursing Considerations for Xanthines: - **Assess:** (PP: 2957-2959) - History and Physical Exam and known allergy. - Peptic ulcer, gastritis, renal or hepatic dysfunction, and coronary disease. - Monitor blood pressure, pulse, cardiac auscultation, peripheral perfusion, and baseline electrocardiogram ECG. - Skin, BS, liver and renal function, appropriate lab values, as well as theophylline levels. - **Important Teaching Points** - Take theophylline as directed by your doctor. Do not stop taking it without talking to your doctor first. - If you miss a dose, take it as soon as you remember, unless it is almost time for your next dose. Do not take a double dose to make up for a missed dose. - Do not take more theophylline than your doctor prescribes. - Do not take theophylline with any other medication without first talking to your doctor. - Avoid drinking grapefruit juice while taking theophylline. - Avoid drinking alcohol while taking theophylline. - Avoid smoking cigarettes while taking theophylline. - Do not take theophylline if you are pregnant or breastfeeding without first talking to your doctor. - Keep theophylline out of reach of children. Store theophylline in a cool, dry place. # Prototype Xanthines: - **Prototype Summary: Theophylline** - **Indications:** Symptomatic relief or prevention of bronchial asthma and reversible bronchospasm associated with chronic bronchitis and emphysema. - **Actions:** Directly relaxes bronchial smooth muscle, causing bronchodilation and increasing vital capacity; also increases force of diaphragmatic muscle. - **Pharmacokinetics:** - **Route** - Oral - IV - **Onset** - 1-6 h - Immediate - **Peak** - 4-8 h - 30 min - **Duration** - 6-8 h - 4-8 h - **T1/2:** About 8 hours for oral but may vary per population and type of formulation. - **Adverse Effects:** Irritability, restlessness, dizziness, palpitations, life-threatening arrhythmias, loss of appetite, proteinuria, respiratory arrest, fever, flushing. # Prototype Sympathomimetics - **Prototype Summary: Epinephrine** - **Indications:** Treatment of anaphylactic reactions, acute asthmatic attacks; relief from respiratory distress of COPD and bronchial asthma. - **Actions:** Reacts at alpha- and beta-receptor sites in the sympathetic nervous system to cause bronchodilation, increased heart rate, increased respiratory rate, and increased blood pressure. - **Pharmacokinetics:** - **Route** - SC - IM - IV - Inhalation - **Onset** - 5-10 min - 5-10 min - Instant - 3-5 min - **Peak** - 20 min - 20 min - 20 min - 20 min - **Duration** - 20-30 min - 20-30 min - 20-30 min - 1-3 h - **T1/2:** Unknown; metabolized by normal neural pathways. - **Adverse Effects:** Fear, anxiety, restlessness, headache, nausea, decreased renal formation, pallor, palpitation, tachycardia, local burning and stinging, rebound congestion with nasal inhalation. # Prototype Anticholinergics: - **Prototype Summary: Ipratropium** - **Indications:** Maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease; treatment of seasonal allergic rhinitis as a nasal spray. - **Actions:** Anticholinergic that blocks vagally mediated reflexes by antagonizing the action of acetylcholine. - **Pharmacokinetics:** - **Route** - *Inhalation* - **Onset** - 15 min - **Peak** - 1-2 h - **Duration** - 3-4 h - **T1/2:** Unknown; metabolized by neural pathways. - **Adverse Effects:** Nervousness, dizziness, headache, nausea, GI distress, cough, palpitations. - **Important Teaching Points** - Use an inhaler as directed by your doctor. Do not stop using an inhaler without talking to your doctor first. - If you miss a dose, take it as soon as you remember, unless it is almost time for your next dose. Do not take a double dose to make up for a missed dose. - Do not take more than your doctor prescribes. - Keep your inhaler out of reach of children. Store your inhaler at room temperature. - Do not use a spacer that you have not been instructed to use. - Do not use the inhaler if it is damaged or blocked. - Do not use the inhaler if it is expired. Always check the expiration date on the inhaler.