Chapter 41 Drugs for Lower Respiratory Disorders Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

2 Chronic Obstructive Pulmonary Disease (COPD)  Pathophysiologic changes  Airway obstruction with increased airway resistance to airflow  Major disorders  Chronic bronchitis  Bronchiectasis  Emphysema  Asthma Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

3 Chronic Obstructive Pulmonary Disease (COPD) (Cont.) Signs and Symptoms of Chronic Obstructive Pulmonary Disease (COPD) Conditions Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

4 Restrictive Lung Disease  Pathophysiologic changes  Decrease in total lung capacity from Fluid accumulation Loss of elasticity of the lung tissues  Etiology  Pulmonary fibrosis  Pneumonitis  Lung tumors  Thoracic deformities (scoliosis)  Myasthenia gravis Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

5 Asthma  Inflammatory disorder of the airway walls associated with a varying amount of airway obstruction  Triggered by Stress Allergens Pollutants  Manifestations  Bronchospasm  Wheezing  Mucus secretions  Dyspnea Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

6 Bronchial Asthma Factors Contributing to Bronchoconstriction Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

7 Chronic Bronchitis  Progressive lung disease caused by smoking or chronic lung infections  Caused by Smoking Chronic lung infections  Manifestations  Bronchial inflammation  Excessive mucous secretion, productive cough  Airway obstruction  Rhonchi  Hypercapnia  Respiratory acidosis Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

8 Bronchiectasis  Abnormal dilation of the bronchi and bronchioles  Caused by Frequent infection Inflammation  Bronchioles become obstructed by the breakdown of the epithelium of the bronchial mucosa.  Tissue fibrosis may result. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

9 Emphysema  Progressive lung disease  Caused by Cigarette smoking Atmospheric contaminants Lack of the alpha 1 -antitrypsin protein  Proteolytic enzymes released in the lung  Terminal bronchioles become plugged with mucus.  Alveolar walls are destroyed.  Air trapped in the alveoli  Inadequate gas exchange Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

10 Bronchodilators  Sympathomimetics  Epinephrine (Adrenalin) Action  Increases cAMP in lung tissue causing bronchodilation  Restores circulation and increases airway patency  First line of defense in acute asthma attack or anaphylaxis, given subQ Side effects  Palpitations, dizziness  Nervousness, tremors  Tachycardia, dysrhythmias, hypertension Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

11 Selective Beta2 Receptor Agonists  Albuterol (Proventil, Ventolin)  Bronchodilation  Rapid onset of action  Longer duration of action  Few side effects  Metaproterenol (Alupent)  Administered oral, inhalation, metered-dose inhaler nebulize Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

12 Bronchodilators (Cont.)  Nonselective beta-adrenergic agonists  Isoproterenol (Isuprel) Action: relaxes smooth muscle of bronchi Severe side effects from beta 1 response; it is seldom prescribed. Administration: IV, inhalation Side effects: nervousness, tremors, restlessness, flushing, HA, tachycardia, palpitations, hypertension Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

13 Bronchodilators (Cont.)  Anticholinergics  Tiotropium (Spiriva) Used for maintenance treatment of bronchospasms associated with COPD Administered by inhalation only with the HandiHaler device (dry-powder capsule inhaler) Adverse effects: dry mouth, constipation, vomiting, dyspepsia, abdominal pain, depression, insomnia, headache, joint pain, peripheral edema, and chest pain Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

14 Bronchodilators (Cont.)  Anticholinergics  Ipratropium bromide (Atrovent)–used to treat asthma  Combination of ipratropium bromide with albuterol sulfate (Combivent)–used to treat chronic bronchitis Action: dilates bronchioles Administration: aerosol inhaler Caution  Narrow-angle glaucoma Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

15 Bronchodilators (Cont.)  Patients who use a beta-agonist inhalant should administer it 5 minutes before using ipratropium.  When using the anticholinergic agent in conjunction with an inhaled glucocorticoid (steroid) or cromolyn, the ipratropium bromide should be used 5 minutes before the steroid or cromolyn. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

16 Bronchodilators (Cont.)  Methylxanthine (xanthine) derivatives  Aminophylline—theophylline ethylenediamine (Elixophyllin, Theo-24), dyphylline (Lufyllin) Action: relaxes smooth muscle of bronchi, bronchioles increasing cAMP, promoting bronchodilation Use: maintenance therapy for chronic stable asthma Therapeutic range: 10 to 20 mcg/mL (toxicity greater than 20) Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

17 Bronchodilators (Cont.)  Aminophylline  Contraindications: seizure, cardiac, renal, or liver disorders  Administration: oral, IV  Side effects: dysrhythmias, nervousness, irritability, insomnia, flushing, dizziness, hypotension, seizures, GI distress, intestinal bleeding, hyperglycemia, tachycardia, palpitations, cardiorespiratory collapse Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

18 Nursing Process: Bronchodilators Assessment Nursing diagnoses Planning Nursing interventions  Patient teaching  Cultural considerations Evaluation Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

19 Leukotriene Receptor Antagonists  Zafirlukast (Accolate), montelukast (Singulair), zileuton (Zyflo CR)  Action: reduce inflammatory process and decrease bronchoconstriction  Use: prophylactic and maintenance for chronic asthma  Side effects: dizziness, HA, GI distress, abnormal liver enzymes, nasal congestion, cough, pharyngitis Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

20 Nursing Process: Leukotriene Receptor Antagonists Assessment Nursing diagnoses Planning Nursing interventions  Patient teaching  Cultural considerations Evaluation Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

21 Glucocorticoids (Steroids)  Glucocorticoids  Beclomethasone (Beclonase), dexamethasone (Decadron) Action: antiinflammatory effect Administration  Tablet: triamcinolone (Aristospan), dexamethasone (Decadron), prednisone, prednisolone, and methylprednisolone  Intravenous: dexamethasone (Decadron), hydrocortisone  MDI inhaler: beclomethasone (Beconase) Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

22 Glucocorticoids (Steroids) (Cont.)  Inhaled glucocorticoids  Not helpful in treating a severe asthma attack  May take 1 to 4 weeks for an inhaled steroid to reach its full effect  Intravenous glucocorticoids: acute asthma exacerbations  Tablet glucocorticoids: asthma that requires prolonged glucocorticoid therapy Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

23 Cromolyn (NasalCrom)  Use  Prophylactic treatment of bronchial asthma  Must be taken daily  Not to be used for acute asthmatic attack  Action: NO BRONCHODILITATION; anti- inflammatory effect and suppression of release of histamine  Administration: inhalation  Side effects: cough, bad taste, rebound bronchospasm Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

24 Nedocromil  Use  Prophylactic treatment of bronchial asthma  Not to be used for acute asthmatic attack  Action: antiinflammatory effect and suppression of release of histamine, leukotrienes, and other mediators from the mast cells  Administration: inhalation  Side effects: bad taste  Nedocromil is believed to be more effective than cromolyn. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

25 Drug Therapy for Asthma According to Age  Young Children  Cromolyn and nedocromil are drugs used to treat the inflammatory effects of asthma.  Oral glucocorticoids may be prescribed for the young child to control a moderate to severe asthmatic state.  Older Adults: careful consideration due to adverse effects Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

26 Mucolytics  Acetylcysteine (Mucomyst)  Action Liquefies and loosens thick mucus secretions  Administration Administer 5 minutes after a bronchodilator. Should not be mixed with other drugs  Also an antidote for acetaminophen overdose if within 12 to 24 hours Give orally diluted in juice or soft drink.  Dornase alfa (Pulmozyme)  Enzyme that digests deoxyribonucleic acid (DNA) in thick sputum secretions of patients with cystic fibrosis (CF) Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

27 Antimicrobials  Trimethoprim-sulfamethoxazole  Treatment of mild to moderate acute exacerbations of chronic bronchitis (AECB) from infectious causes Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

28 Practice Question #1 A patient is ordered the following inhalers, a bronchodilator (ipratropium) and a gluco- corticoid (Beclamethasone). The nurse will A.administer the bronchodilator 5 minutes before the glucocorticoid. B.mix the drugs and administer them together. C.administer the glucocorticoid 10 minutes before the bronchodilator. D.administer the glucocorticoid immediately after the bronchodilator. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

29 Practice Question #2 A patient has just received a nebulizer treatment of metaproterenol (Alupent). It is most important for the nurse to assess the patient for the development of which side effect/adverse effect? A.Tremors B.Bradycardia C.Hypotension D.Hypoglycemia Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

30 Practice Question #3 A patient with chronic obstructive pulmonary disease asks the nurse what the albuterol (Proventil) he is taking does. The nurse should inform the patient that albuterol is used to A.mobilize respiratory secretions. B.decrease the cough response. C.increase the work of breathing. D.dilate the larger airways. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

31 Practice Question #4 The nurse is preparing class for patients with asthma. The nurse will inform the patients that leukotriene modifiers are used in the treatment of asthma to A.assist in opening narrowed airways. B.suppress the release of histamine and other mediators from the mast cells. C.loosen mucus from the airways. D.prevent serious complications from bacterial infections. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

32 Practice Question #5 A patient is using a glucocorticoid inhaler. The patient asks the nurse why he has to rinse his mouth out after using the glucocorticoid inhaler. The nurse should inform the patient that rinsing the mouth is done to A.avoid mucous membrane breakdown. B.increase hydration of the oral mucosa. C.decrease risk of infection. D.slow the development of cavities. Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

33 Practice Question #6 A home care nurse is visiting a patient with asthma who suddenly experiences an acute asthma attack. Which drug should the nurse prepare to administer? A.Zafirlukast (Accolate) B.Nedrocromil sodium (Tilade) C.Metaproterenol (Alupent) D.Zileuton (Zyflo) Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

34 Practice Question #7 A patient with chronic bronchitis is admitted to the health care facility for treatment of a bacterial respiratory infection. Which antimicrobial will most likely be ordered for the patient? A.Seldane B.Amphotericin B C.Acyclovir D.Trimethoprim-sulfamethoxazole Copyright © 2015, 2012, 2009, 2006, 2003, 2000, 1997, 1993 by Saunders, an imprint of Elsevier Inc.