Respiratory Drugs F2024 Student Slides PDF

RESPIRATORY DRUGS Week 11 Prof. Elliott CHAPTER 37 Upper Respiratory Tract Infections 2 TREATMENT OF THE COMMON COLD Involves the use of antihistamines, nasal decongestants, antitussives and expectorants Symptomatic trea...

RESPIRATORY DRUGS Week 11 Prof. Elliott CHAPTER 37 Upper Respiratory Tract Infections 2 TREATMENT OF THE COMMON COLD Involves the use of antihistamines, nasal decongestants, antitussives and expectorants Symptomatic treatment (not curative) Symptomatic treatment does not eliminate the causative pathogen Difficult to identify whether cause is viral or bacterial Treatment is “empirical therapy,” treating the most likely cause Antivirals and antibiotics may be used, but a definite viral or bacterial cause may not be easily identified. PEDIATRIC CONCERNS In 2009, Health Canada issued recommendations that over-the-counter (OTC) cough and cold products not be given to children younger than 6 years of age. Not effective in small children, and parents are advised to consult their pediatrician on the best ways to manage these illnesses. None of these medications are considered “safe” for children < 6 4 RHINOVIRUS/INFLUENZA Common cold Viruses invade the upper respiratory tract to cause an URTI Causes inflammation, nasal congestion, increased mucous production → causes sore throat, coughing, sinus congestion, facial pressure, fatigue, malaise, loss of appetite Rhinitis -inflammation of nasal mucosa 5 WHAT HAPPENS? UPPER RESPIRATORY TRACT INFECTION (URTI): SINUSITIS Symptoms: Sore throat, cough, lymphadenopathy, fever, runny nose, sinus pressure Treatment: Dependent on cause Bacterial: antibiotic Viral: symptomatic Immunization to prevent HARRINGTON, 2011; ADAMS, 2010, COPD 2008; ASTHMA 2012 7 URTI: PHARYNGITIS Treatment: Symptoms: Viral: symptomatic Throat swab Bacterial: antibiotic Other causes of sore throat? 8  ANTIHISTAMINES Drugs that directly compete with histamine for specific receptor sites Histamine antagonists  H1-antagonists (or H1-blockers)  H2-antagonists (or H2 -blockers) 9 HISTAMINE Major inflammatory mediator in many allergic disorders  Allergic rhinitis (e.g., hay fever and mould and dust allergies)  Anaphylaxis  Angioedema  Drug fevers  Insect bite reactions  Urticaria (pale red, raised, itchy bumps) 10 ANTIHISTAMINES Histamine is synthesized in mast cells –response to allergen Histamine causes dilation of capillaries, contraction of smooth muscle, stimulation of gastric acid secretion and acceleration of HR H1 and H2 type (H2—stomach) NOT the focus of today → H1: Anti-histamines compete with histamines (ANTAGONIZE) receptors to block! H1 = ANTIHISTAMINES Palliative/Symptomatic treatment; NOT CURATIVE 11 ANTIHISTAMINES: MECHANISM OF ACTION Block action of histamine at H1-receptor sites Compete with histamine for binding at unoccupied receptors Cannot push histamine off the receptor if already bound More effective in preventing the actions of histamine than in reversing them Should be given early in treatment before all the histamine binds to the receptors 12 LET’S COMPARE Histamine effects Antihistamine Effects Cardiovascular: Dilation and increased Cardiovascular: vasoconstriction, permeability decreased permeability Stimulation of salivary, gastric, lacrimal Reduction of salivary, gastric, lacrimal and bronchial secretions and bronchial secretions Mast cells release inflammatory Bind to prevent release of mediators histamine/inflammatory mediators ANTIHISTAMINES: TWO TYPES Traditional: brompheniramine, chlorpheniramine, dimenhydrinate, diphenhydramine, and promethazine Nonsedating: loratadine, cetirizine, and fexofenadine  Longer duration of action (increases compliance with once-daily dosing) 14 ANTIHISTAMINES: P FORMULARY Use: Adverse: Allergic rhinitis, common cold Drowsiness, dry mouth, hypertension symptoms, allergic reactions, Antihistamine, anticholinergic, sedation –CNS insomnia, vertigo Nursing: Common: Condition specific Loratadine/claritin-Non Drowsy DROWSINESS -Warn driving etc. Diphenhydramine/Benadryl Allergy Action: H1Receptors Some anti-cholinergic effects 15  ANTIHISTAMINES: PATIENT TEACHING Best tolerated when taken with meals; reduces gastrointestinal upset If dry mouth occurs, teach patients to perform frequent mouth care, chew gum, or suck on hard candy (preferably sugarless) to ease discomfort. Monitor for intended therapeutic effects. 16 ANTIHISTAMINES: ADVERSE EFFECTS Anticholinergic (drying) effects: most common  Dry mouth  Difficulty urinating -BPH  Constipation  Changes in vision -Glaucoma Cardiovascular, central nervous system, gastrointestinal, and other effects - HTN Drowsiness  Mild drowsiness to deep sleep 17  ANTIHISTAMINES: CONTRAINDICATIONS Known drug allergy Acute-angle glaucoma Cardiac disease, hypertension Kidney disease Peptic ulcer disease Seizure disorders BPH Bronchial asthma, chronic obstructive pulmonary disease (COPD) Not to be used as sole drug therapy during acute asthmatic attacks  salbutamol or epinephrine! 18 NASAL CONGESTION Excessive nasal secretions Inflamed and swollen nasal mucosa Primary causes  Allergies  Upper respiratory infection (common cold) 19 DECONGESTANTS Nasal Decongestion = excessive nasal secretions/inflammation Three Groups: 1. Adrenergics (Sympathomimetics) * largest group [recall week 1] 2. Anticholinergics (Parasympatholytics)—less commonly used 3. Corticosteroids (topical or intranasal) 20 DECONGESTANTS: RECALL FROM WEEK 1 Use: Nasal congestion Common: Pseudoephedrine: oral –adrenergic drug (longer duration of action/delayed onset Oxymetazoline/Dristan, nasal spray-adrenergic drug, rebound congestion* Mometasone furoate/nasonex -nasal steroid-anti inflammatory response –not associated with rebound effect (different mechanism of action) 21 DECONGESTANTS: Adverse: Nursing: Oral: insomnia, palpitations— Nasal application WHY??* Warn rebound edema/congestion (topical spray) Other health conditions Nasal: mucosa irritation Rebound congestion (adrenergic) 22 INHALED INTRANASAL STEROIDS AND ANTICHOLINERGIC DRUGS Not associated with rebound congestion Often used prophylactically to prevent nasal congestion in patients with chronic upper respiratory tract symptoms 23 NASAL DECONGESTANTS: ADVERSE EFFECTS Adrenergics Steroids Nervousness Local mucosal dryness Insomnia and irritation Palpitations Tremors (Systemic effects caused by adrenergic stimulation of the heart, blood vessels, and central nervous system) 24 TOPICAL NASAL DECONGESTANTS Adrenergics – reduces swelling & congestion  ephedrine Intranasal steroids – reduces swelling  beclomethasone dipropionate budesonide Intranasal anticholinergic – stops mucous  ipratropium 25 NASAL DECONGESTANTS: INDICATIONS May also be used to reduce swelling of the nasal passage and facilitate visualization of the nasal or pharyngeal membranes before surgery or diagnostic procedures 26 NASAL DECONGESTANTS: CONTRAINDICATIONS Drug allergy Acute-angle glaucoma Uncontrolled cardiovascular disease, hypertension [DO NOT USE with MAOI drugs] Diabetes and hyperthyroidism Prostatitis Inability to close the eyes 27 NASAL DECONGESTANTS: PATIENT TEACHING Patients should avoid caffeine and caffeine-containing products. Patients should report a fever, cough, or other symptoms lasting longer than 1 week. Monitor for intended therapeutic effects. 28  COUGH PHYSIOLOGY Respiratory secretions and foreign objects are naturally removed by the cough reflex.  Induces coughing and expectoration  Initiated by irritation of sensory receptors in the respiratory tract Productive cough: congested; removes excessive secretions Nonproductive cough: dry cough 29  COUGHING Most of the time, coughing is beneficial.  Removes excessive secretions  Removes potentially harmful foreign substances In some situations, coughing can be harmful, such as after hernia repair surgery. 30 ANTITUSSIVES Cough = normal physiological function Antitussives are used to stop the cough reflex when the cough is nonproductive or harmful Opioid and Non-opioid Forms ***Which opioid is indicated as an antitussive? Non-opioid = less effective! 31 ANTITUSSIVES: Use: Cough → act on cough center of brain to suppress reflex Common: 1. Codeine-opioid, CNS depression (supress cough centre in medulla + drying effect in CNS) Codeine or Hydrocodone/Hycodan 2. Dextromethorphan/Benylin-non opioid, CNS cough center 32 ANTITUSSIVES: Adverse effects: Dextromethorphan (Benalyin): Codeine: Don’t use hyperthyroidism, MAOIs, CNS depression unstable heart disease, HTN Alcohol or other sedatives Constipation Nursing: Controlled substance Why the cough? [identify cause!] Respiratory depression Drug allergy 33 ANTITUSSIVES: ADVERSE EFFECTS Dextromethorphan  Dizziness, drowsiness, nausea Opioids  Sedation, nausea, vomiting, lightheadedness, constipation Diphenhydramine (Benadryl):  Sedation, dry mouth, and other anticholinergic effects 34 ANTITUSSIVES: NURSING IMPLICATIONS Report any of these symptoms to the caregiver:  Cough that lasts more than 1 week  Persistent headache  Fever  Rash Antitussive drugs are for nonproductive coughs. Monitor for intended therapeutic effects. 35 EXPECTORANTS Drugs that aid in the expectoration (removal) of mucus Reduce the viscosity of secretions Disintegrate and thin secretions  Example: guaifenesin guaifenesin & dextromethorphan included! 36 EXPECTORANTS: MECHANISMS OF ACTION Reflex stimulation  Irritation of the gastrointestinal tract  Loosening and thinning of respiratory tract secretions occur in response to this irritation. Direct stimulation  The secretory glands are stimulated directly to increase their production of respiratory tract fluids. Final result: thinner mucus that is easier to remove 37  EXPECTORANTS: INDICATIONS Used for the relief of productive coughs associated with:  Common cold  Bronchitis  Laryngitis  Pharyngitis  Coughs caused by chronic paranasal sinusitis  Pertussis  Influenza  Measles 38  EXPECTORANTS: NURSING IMPLICATIONS Expectorants should be used with caution in older adults and patients with asthma or respiratory insufficiency. Patients taking expectorants should receive more fluids, if permitted, to help loosen and liquefy secretions. Report a fever, cough, or other symptoms lasting longer than 1 week. Monitor for intended therapeutic effects. 39 EXPECTORANTS: Use: increase expectoration of sputum Common: Guaifenesin/Robitussin Nursing: ? Is there a place for this → trach care is one example Clinical effectiveness is not demonstrated in studies! HARRINGTON, 2011; ADAMS, 2010, COPD 2008; ASTHMA 2012 40 ALTERNATIVE TX Should people take more vitamin C when they are sick? What about echinacea ? Honey? Zinc? 41 SUPPLEMENTS AND HERBAL PRODUCTS Vitamin C  Findings _______________ Echinacea  Herb – thought to reduce chemicals that decrease ___________ Goldenseal  Herb – though to have an effect against bacteria and fungi 42  NCLEX REVIEW QUESTION Before administering an antihistamine to a patient, it is most important for the nurse to assess the patient for a history of which condition? A. Chronic urticaria B. Motion sickness C. Urinary retention D. Insomnia  NCLEX REVIEW QUESTION A 94-year-old patient has a severe dry cough. He has coughed so hard that the muscles in his chest are hurting. He is unsteady on his feet and slightly confused. Which drug would be the best choice for this patient’s cough? A. benzonatate capsules Dextromethorphan does not B. dextromethorphan oral solution cause respiratory or CNS depression, and it is not an C. Codeine cough syrup opioid. Guaifenesin is an expectorant that is used to thin D. guaifenesin excessive mucus, which this patient does not have. 44 NCLEX REVIEW QUESTION A patient with a tracheostomy developed pneumonia. It is very difficult for the patient to cough up the thick, dry secretions that have developed. The nurse identifies which medication as being most effective in helping this patient? A. benzonatate (Tessalon Perles) capsules B. dextromethorphan (Benylin DM-E) oral solution C. codeine cough syrup D. guaifenesin (Robitussin) RESPIRATORY DRUGS Chapter 38  Asthma (persistent and present most of the time despite treatment) DISEASES OF THE LOWER RESPIRATORY TRACT Chronic obstructive pulmonary disease (COPD) Formerly known as emphysema and chronic bronchitis BRONCHIAL ASTHMA Recurrent and reversible shortness of breath Occurs when the airways of the lungs become narrow as a result of:  Bronchospasms  Inflammation of the bronchial mucosa  Edema of the bronchial mucosa  Production of viscous mucus The alveolar ducts and alveoli remain open, but airflow to them is obstructed. Symptoms  Wheezing How Do We Know Meds are Working?  Difficulty breathing FEV1/FVC ratio is n important way of monitoring effectiveness of treatment. If effective = greater than 80% SPIROMETRY The amount of air exhaled forcefully over one second FEV1 The amount of that can be forcefully exhaled by breathing out for as long as possible after a full inspiration https://youtu.be/xTzoJdNDl6w?si=pB_UNQWBtakYNawh What is spirometry https://youtu.be/ow5THCmmLLc?si=gqDvpCQ9uJ62LCYM [what is FEV1] 49 ASTHMA A sudden and dramatic onset is referred to as an asthma attack. Prolonged asthma attack that does not respond to typical drug therapy is known as status asthmaticus. Status asthmaticus  Prolonged asthma attack that does not respond to typical drug therapy  May last several minutes to hours  Medical emergency TREATMENT?? ASTHMA MANAGEMENT CONTINUUM CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Progressive respiratory disorder Characterized by chronic airflow limitation, systematic manifestations, and significant comorbidities Presence of cough and sputum for at least 3 months in each of 2 consecutive years Separate disease from chronic obstructive pulmonary disease  Grade 1: Breathless with strenuous exercise Grade 2: Short of breath when hurrying on the level or walking up a slight hill COPD: Grade 3: Walks slower than people of the same age on DISABILITY the level of stops for breath while walking at own pace on the level ASSESSMENT Grade 4: Stops for breath after walking 100 yards Grade 5: Too breathless to leave the house or breathless when dressing COPD: COLLABORATIVE CARE Drug therapy Bronchodilators Relax smooth muscle in the airway Improve ventilation of the lungs ↓ Dyspnea and ↑ FEV1 Inhaled route is preferred. 54 BRONCHODILATORS Bronchodilators  Relax bronchial smooth muscle, which causes dilation of the bronchi and bronchioles that are narrowed as a result of the disease process  Three classes: β-adrenergic agonists, anticholinergics, and xanthine derivatives  Short-acting ß-agonist (SABA) inhalers salbutamol (Ventolin®) →RESCUE BRONCHODILATORS: Terbutaline sulphate (Bricanyl®) ß-ADRENERGIC AGONISTS Long-acting ß-agonist (LABA) inhalers formoterol (Foradil®, Oxeze®) salmeterol (Serevent®) BRONCHODILATORS: ß2-ADRENERGIC AGONISTS Used during acute phase of asthmatic attacks Quickly reduce airway constriction and restore normal airflow Agonists, or stimulators, of the adrenergic receptors in the sympathetic nervous system  Sympathomimetics RESCUE INHALER ß-ADRENERGIC AGONISTS: SALMETEROL ® (SEREVENT ) Long-acting ß2-agonist bronchodilator Never to be used alone but in combination with an inhaled glucocorticoid steroid Used for the maintenance treatment of asthma and COPD; salmeterol maximum daily dose (one puff twice daily) should not be exceeded. INHALERS: PATIENT EDUCATION For any inhaler prescribed, ensure that the patient is able to self-administer the medication.  Provide a demonstration and a 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.  BETA-ADRENERGIC BRONCHODILATORS Salbutamol (Ventolin) Serevent Diskus Inhaler Inhaler  NURSING IMPLICATIONS: ß-ADRENERGIC AGONISTS Ensure that patients take medications exactly as prescribed, with no omissions or double doses. Inform patients to report insomnia, jitteriness, restlessness, palpitations, chest pain, or any change in symptoms (common side effects) Don’t take ________s for pain control, may worsen asthma symptoms ß-ADRENERGIC AGONISTS: INTERACTIONS Diminished bronchodilation when nonselective ß-blockers are used with the ß-agonist bronchodilators Monoamine oxidase inhibitors = ________ Sympathomimetics Monitor patients with diabetes; an increase in blood glucose levels can occur. 63  ANTICHOLINERGICS: MECHANISM OF ACTION Acetylcholine (ACh) causes bronchial constriction and narrowing of the airways. Anticholinergics bind to the ACh receptors, preventing ACh from binding. Result: bronchoconstriction is prevented, airways dilate STATUS ASTHMATICUS? Short-acting inhaled β2-agonists are the first-line drugs for treating acute asthma exacerbation [Nebulized salbutamol] Intramuscular or intravenous epinephrine should be considered when aerosolized albuterol is ineffective or cannot be administered or if an allergen triggered the asthma attack. [Epinephrine IM/IV] Methylprednisolone dose of 125 mg intravenously in emergency room presentations. [Corticosteroid IV] ANAPHYLAXIS: SEVERE ALLERGIC REACTIONS Release of excessive amounts of histamine can lead to:  Constriction of smooth muscle, especially in the stomach and lungs  Increase in body secretions  Vasodilatation and increased capillary permeability, movement of fluid out of the blood vessels and into the tissues, and drop in blood pressure and edema 66  ANTICHOLINERGICS ipratropium (Atrovent®), tiotropium bromide monohydrate (Spiriva®) Indirectly cause airway relaxation and dilation Help reduce secretions in COPD patients Indications: prevention of the bronchospasm associated with COPD; NOT for the management of acute symptoms ANTICHOLINERGICS: ADVERSE EFFECTS Dry mouth or throat (expected) Heart palpitations (expected) Gastrointestinal symptoms (expected) Urinary retention (expected) Increased intraocular pressure Headache (expected) Coughing (expected) Anxiety (expected) ANTICHOLINERGICS: IPRATROPIUM BROMIDE (ATROVENT) Oldest and most commonly used anticholinergic bronchodilator Available both as a liquid aerosol for inhalation and as a multidose inhaler Usually dosed twice daily ANTICHOLINERGIC BRONCHODILATORS Ipratropium Bromide Tiotropium bromide (Atrovent) Inhaler (Spiriva) You DO NOT swallow this pill ACUTE ASTHMA? 1. Beta 1 adrenergic inhaler (Salbutamol or Albuterol) 2. Anticholinergic inhaler (could nebulizer; Ipratropium) 3. Methylprednisolone (Solumedrol) IV administration! NEBULIZER TREATMENT NEBULIZER TREATMENT MASK "File:Nebulizer.JPG" by James Heilman, MD is licensed under CC BY- SA 4.0 ASSESSMENT? How do you know if your patient is improving?? Decrease in tachypnea/RR Decrease in dyspnea Oxygen sat > 90% Decreased anxiety Increased productive cough INHALED CORTICOSTEROIDS Budesonide (Pulmicort) Fluticasone (Flovent) Turbo Inhaler Inhaler/Diskus CORTICOSTEROIDS (GLUCOCORTICOIDS) Anti-inflammatory properties Used in treatment of pulmonary diseases May be administered intravenously Oral or inhaled forms  Inhaled forms reduce systemic effects. May take several weeks before full effects are seen CORTICOSTEROIDS: MECHANISM OF ACTION Stabilize membranes of cells that release harmful bronchoconstricting substances Increase responsiveness of bronchial smooth muscle to ß-adrenergic stimulation Dual effect of both reducing inflammation and enhancing the activity of ß- agonists  INHALED CORTICOSTEROIDS beclomethasone dipropionate (Qvar®) budesonide (Pulmicort Turbuhaler®) fluticasone furoate (Avamys®) fluticasone propionate (Flovent Dickus®) ciclesonide (Omnaris®) INHALED CORTICOSTEROIDS: ADVERSE EFFECTS Pharyngeal irritation Coughing Dry mouth Oral fungal infections Systemic effects are rare because low doses are used for inhalation therapy. PATIENT TEACHING Teach patients to gargle and rinse the mouth with lukewarm water afterward to prevent the development of oral fungal infections. If a ß-agonist bronchodilator and corticosteroid inhaler are both ordered, the bronchodilator should be used several minutes before the corticosteroid to provide bronchodilation before administration of the corticosteroid. COMBINATION INHALERS Symbicort (combo ICS w LABD) Combo of Budesonide and Advair (combo ICS w LABD) Formoterol BRONCHODILATORS: Β- ADRENERGIC AGONISTS: NEWEST Long-acting ß-agonist and glucocorticoid steroid combination inhaler  budesonide/formoterol fumarate dihydrate (Symbicort®)  Use as a reliever or rescue treatment for moderate to severe asthma when symptoms worsen COPD MEDICATIONS (INHALERS) COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. NURSING IMPLICATIONS: ASSESSMENT Perform a thorough assessment before beginning therapy, including:  Skin colour  Baseline vital signs  Respirations (should be between 12 and 20 breaths/min)  Respiratory assessment, including pulse oximetry  Sputum production  Allergies  History of respiratory problems  Other medications NURSING IMPLICATIONS Monitor for therapeutic effects.  Decreased dyspnea  Decreased wheezing, restlessness, and anxiety  Improved respiratory patterns with return to normal rate and quality  Improved activity tolerance  Decreased symptoms and increased ease of breathing PATIENT TEACHING Teach patients to take bronchodilators exactly as prescribed. Ensure that patients know how to use inhalers and metered-dose inhalers, and have patients demonstrate the use of the devices. Monitor for adverse effects. NCLEX QUESTION A patient is being discharged with inhaled beclomethasone. What is essential to include in discharge teaching regarding this medication? Select All That Apply (SATA) A. Monitor your blood sugar frequently, this medication can elevate your blood sugar levels B. Stay away from big crowds, this medication weakens your immune system C. Rinse your mouth out after administration, this medication can cause fungal infections D. Drink lots of water, this medication can cause dehydration E. Monitor your blood pressure, this medication elevates your BP level COPD:EXACERBATIONS GOLD C and D patients are high-risk patients defined by frequent exacerbations and/or a severe exacerbation requiring hospitalization Associated with poorer outcomes Primary causes  Infection  Air pollution PREDNISONE! 88  CORTICOSTEROIDS: DRUG INTERACTIONS Drug interactions are more likely to occur with systemic (versus inhaled) corticosteroids. May increase serum glucose levels, possibly requiring adjustments in dosages of antidiabetic drugs May raise the blood levels of the immunosuppressants cyclosporine and tacrolimus; itraconazole may reduce clearance of the steroids Phenytoin, phenobarbital, and rifampin Greater risk of hypokalemia with concurrent diuretic use (e.g., furosemide, hydrochlorothiazide) RECALL: ORAL CORTICOSTEROIDS Use: Adverse/caution: Many! Immunosuppressant Exacerbations of COPD and Asthma  Risk for opportunistic infections Severe not responding to usual management Diabetes  hyperglycemia PUD: bleeding Common: OP Prednisone Growth suppression Pediapred Weight gain Mood changes Action: Thin skin/bruise easily Anti-inflammatory Insomnia Fluid retention  Edema/ HTN 90  XANTHINE DERIVATIVES [RECALL WEEK 6-CNS PART 1] Plant alkaloids: caffeine, theobromine, and theophylline Only theophylline and caffeine are currently used clinically. Synthetic xanthines: aminophylline Increase levels of energy-producing cyclic adenosine monophosphate (cAMP)  This is done by competitively inhibiting phosphodiesterase, the enzyme that breaks down cAMP. Not used as frequently for chronic management of asthma and COPD because of potential for drug interactions and variables related to drug levels in the blood  XANTHINE DERIVATIVES: THEOPHYLLINE Most commonly used xanthine derivative Oral and injectable (as aminophylline) dosage forms Aminophylline: intravenous (IV) treatment of patients with status asthmaticus who have not responded to fast-acting ß-agonists such as epinephrine Therapeutic range for theophylline blood level is 55 to 100 mmol/L. Canadian Asthma Consensus guideline recommends levels between 28 to 55 mmol/L. NURSING IMPLICATIONS: XANTHINE DERIVATIVES Contraindications: history of peptic ulcer disease or gastrointestinal disorders Cautious use: cardiac disease  Report to most responsible HCP: Restlessness, Insomnia, Tremors, Irritability  Teach patient to not smoke (nicotine) = CNS stimulant Timed-release preparations should not be crushed or chewed (causes gastric irritation). NONBRONCHODILATING RESPIRATORY DRUGS Leukotriene receptor antagonists (montelukast, zafirlukast) Corticosteroids (beclomethasone, budesonide, dexamethasone, flunisolide, fluticasone, ciclesonide, and triamcinolone) Mast cell stabilizers: rarely used and no longer included in Canadian Asthma Management Continuum Monitor neutrophil counts LEUKOTRIENE RECEPTOR ANTAGONISTS Nonbronchodilating Newer class of asthma medications Currently available drugs  montelukast (Singulair®)  zafirlukast (Accolate®)  LEUKOTRIENE RECEPTOR ANTAGONISTS: DRUG EFFECTS By blocking leukotrienes  Prevent smooth muscle contraction of the bronchial airways  Decrease mucus secretion  Prevent vascular permeability  Decrease neutrophil and leukocyte infiltration to the lungs, preventing inflammation LEUKOTRIENE RECEPTOR ANTAGONISTS: INDICATIONS Prophylaxis and long-term treatment and prevention of asthma in adults and children  Montelukast safe in children 2 years of age and older  Zafirlukast safe in children 12 years of age and older Not meant for management of acute asthmatic attacks Montelukast is also approved for treatment of allergic rhinitis Improvement with their use is typically seen in about 1 week LEUKOTRIENE RECEPTOR ANTAGONISTS: ADVERSE EFFECTS Both drugs (montelukast (Singulair), zafirlukast) may lead to liver dysfunction. zafirlukast  Headache, nausea, diarrhea  Coadministration of inhaled glucocorticoids increases the risk of upper respiratory infection  SUICIDE Risk?? → STRONG warning on montelukast PHOSPHODIESTERASE TYPE 4 INHIBITOR roflumilast (Daxas®)  Indicated to prevent coughing and excess mucus from worsening and to decrease the frequency of life-threatening COPD exacerbations  Trying to prevent frequent exacerbations/hospitalizations  Adverse effects include nausea, diarrhea, headache, insomnia, dizziness, weight loss, and psychiatric symptoms (anxiety and depression) –call HCP  Most common side effects are diarrhea, weight loss, nausea, headaches, insomnia MONOCLONAL ANTIBODY ANTIASTHMATIC omalizumab (Xolair®)  Selectively binds to immunoglobulin E, which in turn limits the release of mediators of the allergic response  Omalizumab is given by injection.  Potential for producing anaphylaxis  Monitor closely for hypersensitivity reactions. NCLEX REVIEW QUESTION Which medication will the nurse teach a patient with asthma to use when the patient is experiencing an acute asthma attack? A. salbutamol (Ventolin®) B. salmeterol (Serevent®) C. theophylline (Theolair®) D. montelukast (Singulair®) NCLEX REVIEW QUESTION A client with COPD has hypertension, which of the following antihypertensive medications would be contraindicated? A. ACE inhibitors B. Beta blockers C. Calcium channel blockers D. Diuretics NCLEX REVIEW QUESTION A client calls their nurse practitioner to report the most common side effects of taking salbutamol, what does the nurse expect them to report? A. Constipation B. Palpitations C. Skin rash D. Tremors E. Difficulty sleeping NCLEX REVIEW QUESTION A patient with chronic bronchitis calls the office for a refill of a salbutamol inhaler. The patient, who just had the prescription filled 2 weeks ago, says the inhaler is empty. When asked, the patient 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. NCLEX REVIEW QUESTION The nurse is providing teaching to a group of individuals with chronic obstructive pulmonary disease at a community centre. 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 1 kg or more in 24 hours or 2.5 kg 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 (Theolair), I will advise my prescriber if I experience epigastric pain.”