Respiratory Agents PDF

Respiratory Agents DR. DEANNA WOMBLE DNP, MSN, APRN, FNP-C, CNE Objectives  Define key terminology related to the respiratory system and medication management of medical conditions that affect the respiratory system  Recall the anatomy and function of the respiratory system  Recal...

Respiratory Agents DR. DEANNA WOMBLE DNP, MSN, APRN, FNP-C, CNE Objectives  Define key terminology related to the respiratory system and medication management of medical conditions that affect the respiratory system  Recall the anatomy and function of the respiratory system  Recall administration of inhalers and nebulized medications and educating patients on self-administration via these routes.  Differentiate between and recognize medical conditions of the upper and lower respiratory tract that necessitate treatment with a pharmacologic agent.  Explain the indications, actions, contraindications, serious and most common adverse effects and nursing implications of select drugs and classifications acting on the upper and lower respiratory tract.  Explain life span considerations for drugs that affect the respiratory system.  Recognize drug-drug interactions, drug-food interactions and/or drug-lab interactions of select drugs that affect the respiratory system.  Recognize and categorize prototype and select drugs from each classification of drugs that affect the upper and lower respiratory system Key Terminology  sinusitis, pharyngitis, rhinitis, laryngitis, bronchitis, pneumonia, chronic obstructive pulmonary disease (COPD), seasonal, perennial, urticaria, bronchospasm, pruritis, epistaxis, rhinitis medicamentosa, dysphonia Need to Know Drugs  Antitussives: benzonatate, codeine, dextromethorphan  Decongestants (nasal and oral): oxymetazoline, phenylephrine  Intranasal glucocorticoids: fluticasone  Antihistamines (first & second generation): diphenhydramine, cetirizine  Expectorants: guaifenesin  Mucolytics: acetylcysteine Need to Know Drugs  Drugs affecting inflammation Inhaled glucocorticoids budesonide (Pulmicort),fluticasone (Flovent), triamcinolone (Azmacort) Leukotriene Receptor Antagonists montelukast (Singulair) Need to Know Drugs  Bronchodilators Beta 2 adrenergic agonists albuterol, formoterol, epinephrine Methylxanthines theophylline Anticholinergics ipratropium (Atrovent), tiotropium (Spiriva) Need to Know Drugs  Corticosteroids- budesonide, fluticasone, triamcinolone Digging Deeper  Anti-tussive-hydrocodone (scheduled)-can be combined with homatropine  Decongestants-naphazoline, pseudoephedrine (Sudafed), tetrahydrozoline, xylometazoline (Otrivin)  Topical Decongestants-Nasal Steroids flunisolide (Nasalide), budesonide (Rhinocort), mometasone (Nasonex), beclomethasone  Antihistamines 1 st gen-brompheniramine (Dimetapp), chlorpheniramine (Chlortrimeton), clemastine (Tavist), cyproheptadine, dexchlopheniramine, promethazine (Phenergan), triprolidine 2 nd gen- acrivastine with pseudoephedrine (combo), azelastine (Astelin), cetirizine (Zyrtec), desloratadine (Clarinex), fexofenadine (Allegra), levocetirizine (Xyzal), loratadine (Claritin), olopatadine (Patanol) Digging Deeper  Bronchodilators/Anti-Asthmatic  Xanthines aminophylline, dyphylline,  Sympathomimetics- arformoterol, indacaterol, levalbuterol, terbutaline,  Anticholinergics aclidinium, tiotropium (Spiriva)  Drugs affecting inflammation  Leukotriene Receptor Antagonists zafirlukast (Accolate), zileuton (Zyflo CR) , roflumilast (Daliresp)  Inhaled corticosteroid beclomethasone, budesonide (Pulmicort), ciclesonide (Alvesco),, mometasone (Asmanex), triamcinolone (Azmacort) Mast cell stabilizers-cromolyn, nedocromil Digging Deeper  Corticosteroids-beclomethasone, ciclesonide, mometasone, flunisolide  Other anti-inflammatory agents roflumilast (Daliresp)-PDE4 inhibitor umeclidinium [Incruse ellipta (long acting muscarinic)] umeclidinium/vilanterol [Anora ellipta (long acting muscarinic +long-acting beta 2 agonist)] fluticasone furoate/vilanterol [Breo ellipta (long-acting beta 2 agonist + corticosteroid), fluticasone/salmeterol (Advair)  The Respiratory Tract Upper Respiratory Tract Lower Respiratory Tract Conditions of the Respiratory System Upper Respiratory System Lower Respiratory System  Common Cold  Pneumonia  Allergic Rhinitis (seasonal and  Bronchitis perennial)  Obstructive Pulmonary Diseases:  Sinusitis Asthma, COPD (emphysema, chronic bronchitis), cystic fibrosis, respiratory  Pharyngitis and Laryngitis distress syndrome Medications LOWER AND UPPER RESPIRATORY TRACT OTC Cold Remedies  Use in children should be limited or used with caution  CDC no in < 2 y.o.  AAP no if < 6 y.o.  Cough and cold labeling: no < 4y.o.  Confusing for parents  Educate  Avoid in children < 4-6 y.o.  Use only pediatric products  Consult PCP prior to using  Read label and use proper measuring device  Stop use and contact PCP if child worsens or doesn’t improve  Avoid antihistamines to sedate children  Symptomatic treatment-hydration, cool mist humidifier, avoid exposure to secondhand smoke/allergens/irritants, hand hygiene. Intranasal Glucocorticoids fluticasone (Flonase)  Indications: seasonal allergic rhinitis; inflammation after removal of nasal polyps  Actions: relieves inflammation; exact mechanism of action is unknown  Contraindications: acute infection (if systemic absorption occurs, worsens infection)  Drug interactions: systemic corticosteroid therapy Intranasal Glucocorticoids  Adverse effects: local burning, irritation, stinging, dryness of the mucosa; epistaxis  Nursing Considerations: Assess for intranasal lesion before administering, administer properly and educate patient on proper administration; if nasal decongestant-give before intranasal glucocorticoid; respiratory and ENT assessment Antihistamines First Generation: diphenhydramine (Benadryl) Second Generation: cetirizine (Zyrtec)  Indications: allergic rhinitis, uncomplicated urticaria, allergic rxn to blood and blood products and adjunctive tx with anaphylaxis, some used for motion sickness and insomnia  Actions: selectively block the effects of histamine-decreasing the allergic response and results in decreased sneezing, rhinorrhea and itching (does not help with nasal congestion); anticholinergic (1 st gen. mainly) and antipruritic effects  Contraindications: other CNS depressants (alcohol), anticholinergics and drugs with anticholinergic properties, glaucoma, BPH  Adverse reactions: drowsiness, sedation, anticholinergic effects (dryness, urinary retention), excitation (children)  Nursing Considerations: minimize symptoms of side effects (dry mouth/mm-lozenges, sugarless candy, oral care, humidifier, push fluids; urinary retention-void frequently; Educate-OTC meds, avoid alcohol and other sedating medications; avoid driving if CNS side effects occur; more effective if started before symptoms; if GI upset give with food; no in infants < 6 mo. (caution if older because of risk of sedation and respiratory depression); older adults more affected by CNS and anticholinergic adverse effects; educate pt.. not to use for longer than recommended, OTC education; respiratory and ENT assessment Decongestants  Can be topical (nasal, ophthalmic) or systemic (oral) Nasal: oxymetazoline (Afrin), phenylephrine, Oral: phenylephrine (Sudafed) Decongestants Topical Nasal Decongestants: oxymetazoline (Afrin), phenylephrine Oral Decongestants: phenylephrine (Sudafed)-alpha specific adrenergic agonist  Indications: relieve discomfort of nasal congestion that accompanies the common cold, sinusitis, and allergic rhinitis  Actions: vasoconstriction and less inflammation to the nasal mucus membrane; decreases overproduction of secretions  Contraindications: lesion or erosion in the mucus membranes (nasal); HTN, cardiac conditions (oral)  Adverse effects: Nasal [local stinging and burning, rebound congestion (rhinitis medicamentosa); if absorbed systemically or excessive dosage may see elevated HR, BP (CNS stimulation-restless, insomnia, anxiety)]; oral (CNS stimulation, elevated HR and BP) Decongestants  Nursing Considerations  Monitor for signs of systemic absorption, assess nasal mucosa prior to administration and throughout treatment for lesions  Administer properly and educate in proper administration  Do not use for more than 5 days  Very effective at relieving congestion short term  Educate pt.. not to use for longer than recommended, OTC education Respiratory and ENT assessment Antitussives codeine (scheduled), dextromethorphan (Delsym), benzonatate (Tessalon)  Indications: controls nonproductive cough; suppresses the cough reflex  Actions: acts directly on the medullary cough center of the brain to depress the cough reflex, *benzonatate (local anesthetic on respiratory passages)  Contraindications: patients who need to cough to maintain an open airway; CNS depression; children 20mcg/mL) restlessness, insomnia, seizures; tachycardia; death  Nursing Considerations: Assess CV, pulse, BP; assess serum theophylline levels or compare to previous levels; Educate smokers and importance of timely follow up for blood levels; drug level affected by pt.. factors that affect metabolism; po or IV in an emergency; monitor for toxicity; resp assessment before and throughout  ipratropium (Atrovent)-also topical nasal Anticholinergics spray, tiotropium (Spiriva)  Indications: maintenance treatment of bronchospasm associated with COPD (off label for asthma); nasal spray (allergic rhinitis and common cold)  Actions: block muscarinic receptors in lungs decreasing bronchoconstriction  Caution: any condition that would be aggravated by the anticholinergic effects of the drug (narrow angle glaucoma, bladder neck obstruction, BPH) Anticholinergics  Adverse effects: systemic absorption rare - if occurs see usual anticholinergic effects (increased i.o.p, tachycardia, urinary retention, constipation, etc.); dry mouth/throat (general AE and if anticholinergic effects)  Drug interactions: other anticholinergics  Nursing Considerations: educate about inhaler use; resp. assessment before and throughout; DuoNeb (albuterol/ipratropium); monitor for anticholinergic effect Combination therapy  Glucocorticoid/LABA (budesonide/formoterol- Symbicort)  Beta 2 adrenergic agonist/Anticholinergic  Nebulizer (DuoNeb-albuterol and ipratropium) Concurrent Drug Therapy  Corticosteroids- budesonide, fluticasone, triamcinolone Po, IM or IV  Anti-infective- antibiotics, antivirals, antifungals, antimycobacterial  Consider possibility of OTC, herbal, homeopathic treatments General Patient Education  Smoking cessation and dangers of smoking  Asthma-avoid triggers and allergens  Proper use of medication delivery device  SABA only for acute attack (bronchoconstriction)  SABA prn  If using SABA more than twice a week, see provider  Regular follow-up  How to monitor for worsening of condition (asthma-peak flow meter), increased use of SABA, worsening of symptoms References  Burchum, J. R. & Rosenthal. L. D. (2022). Lehne’s pharmacology for nursing care (11th ed.). Elsevier.  Colgrove, C. & Doherty, C. (2019). Pharmacology success: NCLEX style Q & A review. (3rd edition). F.A. Davis  Craig, G. P. (2020) Clinical calculations made easy: Solving problems using dimensional analysis (7th ed.). Wolters Kluwer.  Ignatavicius, D.D., Workman, M. L., Rebar, C. R. & Heimgartner, N. M. (2021). Medical-Surgical nursing : Concepts for interprofessional collaborative care (10th ed.). Elsevier.  Lynn, P. (2023). Taylor’s clinical nursing skills (6th ed.). Wolters Kluwer.  Taylor, C., Lynn, P. & Bartlett, JL. (2023 ). Fundamentals of nursing: The art and science of person-centered care (10th ed.). Lippincott, Williams and Wilkins  Vallerand, A. H. & Sanoski, C. A. (2021). Davis drug guide for nurses (17th ed.). F.A. Davis Image References  American Academy of Pediatrics. (n.d.). How to use an MDI closed mouth inhaler. Retrieved on 11/7/23 from https://www.youtube.com/watch?v=_euQJqoD120  American Lung Association. (n.d.). How to properly use a nebulizer. Retrieved on 11/7/23 from https://www.youtube.com/watch?v=pEKFKZiLNaA  Boston Children's Hospital. (n.d.). How to use the respimat inhaler. Retrieved on 11/7/23 from https://www.youtube.com/watch?v=Joe8iZxr_w0  Centers for Disease Control. (n.d.). Using a metered dose inhaler with a spacer. Retrieved on 11/7/23 from https://www.youtube.com/watch?v=_euQJqoD120 Image References  Lung Foundation Australia. (n.d.). Inhaler device technique: Accuhaler. Retrieved on 11/7/23 from https://www.youtube.com/watch?v=9gZAl5q-XnE  Socratic Q & A. (2017). Anatomy & physiology: What structures are in the upper respiratory tract? And lower?. Retrieved on 11/7/23 from https://socratic.org/questions/what-structures-are-in-the-upper- respiratory-tract-and-the-lower  Photos or pictures without a source are from creative commons or are personal photos of the author