1. Drugs for Asthma and Other Pulmonary Disorders
76 & 77
Drugs for Asthma and Other Pulmonary Disorders

2. Respiratory System
The bronchial tree ends in dilated sacs called alveoli
Gases to readily move between the blood and the inspired air.
A semipermeable membrane allows
Oxygen to enter the blood and
Carbon dioxide, and cellular waste products to leave the lungs

3. Autonomic Control of Airways
Bronchioles
Lined with smooth muscle that controls amount of air entering lungs
Diameter of airways controlled by autonomic nervous system
The sympathetic branch activates beta2-adrenergic receptors
Causes bronchiolar smooth muscle to relax

4. Autonomic Control of Airways (continued)
Bronchioles
The airway diameter increases and
Bronchodilation occurs:
Allows air to enter the lungs more freely
Increases the supply of oxygen to the body’s tissues.

5. Autonomic Control of Airways (continued)
The parasympathetic branch
Causes bronchiolar smooth muscle to contract
The airway diameter is narrowed
Bronchoconstriction occurs
Results in less airflow.

6. Asthma & COPD (Table 76-1 page 921)
Antiinflammatory Drugs: Glucocorticoids
Mast Cell Stabilizers
Leukotriene modifier
Short acting beta2 agonist
Long acting beta 2 agonist
Methylxanthine (theophylline)
Antiicholinergic (ipratropium)

7. Administration by Inhalation
Common route of administration for pulmonary drugs
Rapid and efficient
Rich blood supply allows for quick absorption and onset of action
Delivers drugs directly to sites of action

8. Aerosol Therapy Suspension of droplets or particles in a gas
Onset of action almost immediate
Drugs administered for local effect
Immediate relief of bronchospasm
Loosens thick mucus
Side effects are reduced; systemic effects can still occur

9. Aerosol Therapy (continued)
Disadvantages of Aerosol Therapy
Difficult to measure precise dose
Usually, only 10–50% of drug is placed
Instruction may be complicated for some clients
Side effects occur if client swallows drug or does not rinse mouth after inhalation

10. Devices Used for Aerosol Therapy
Nebulizer
Vaporizes liquid drug into fine mist
Uses small machine and face mask

11. Devices Used for Aerosol Therapy (continued)
Metered dose inhaler (MDI)
Propellant delivers measured dose of drug
Client times inhalation to puffs of drug

12. Devices Used for Aerosol Therapy (continued)
Respimats
Dry powder inhaler (DPI)
Client inhales powdered drug
Device activated by inhalation

13. Asthma Is Chronic Disease
Has both inflammatory and bronchospasm components
Table 76-4 page 928 Asthma Classification
Symptoms occur
From exposure to triggers
Upon exertion (exercise induced)

14. Asthma Is Chronic Disease (continued)
Status asthmaticus—prolonged attack
Drugs used to
Prevent asthmatic attacks
Terminate attack in progress

15. Goals of Therapy
Asthma has both bronchoconstriction component and inflammation component
Goals of drug therapy are twofold
To terminate acute bronchospasms in progress
To reduce the frequency of asthma attacks

16. Anti-inflammatory Agents—Glucocorticoids
Primary use: to decrease frequency of asthma attacks
Also for allergic rhinitis
Should not be used to terminate asthma attacks in progress
Adverse effects: oropharyngeal candidiasis

17. Glucocorticoids Potent anti-inflammatory drugs
Inhaled, are drugs of choice for long-term prophylaxis of asthma
Must be taken daily
Systemic side effects rarely observed
Oral drugs used for short-term therapy of severe, acute asthma
Limit therapy to under 10 days.

18. Anti-inflammatory Agents—Glucocorticoids
Prototype drug: beclomethasone (Beclovent, Beconase, Vancenase, Vanceril)
See Table 76-2 page 924
Mechanism of action: acts by suppressing inflammation by:
Decreased synthesis and release of inflammatory mediators (histamine, leukotrienes, prostaglandin)
Decreased infiltration and activity of inflammatory cells (eosinophils, leukocytes)
Decreased edema of the airway mucosa

19. Glucocorticoid Therapy for Asthma
Primary purpose of inhaled glucocorticoids is to prevent respiratory distress
Do not use this medication during acute asthma attack
Adrenal insufficiency –taper dose
Client should watch for signs and symptoms of simple infections
Rinse mouth after using steroid inhalers
Closely monitor blood-glucose levels

20. Beta-Adrenergic Agonists
Most effective drugs for relieving acute bronchospasm
Activate beta2-receptors in bronchial smooth muscle to cause bronchodilation
Fewer cardiac side effects than older nonselective beta-adrenergics
Range from short acting (SABA) to long acting (LABA)
See Table 76-3 page 927

21. Inhalation versus Oral Therapy
Inhalation Therapy
Produces rapid bronchodilation
Little systemic toxicity
Oral Therapy
Longer duration of action
Frequent side effects
Tolerance may develop

22. MDI or DPI
When two inhalations are needed, an interval of 1 minute or longer should separate between inhalations

23. Bronchodilators—Anticholinergic
Prototype drug: ipratropium (Atrovent)
Mechanism of action: causes bronchodilation by blocking cholinergic receptors in bronchial smooth muscle
Occasionally used as alternative to beta-agonists in asthma therapy
Used in inhaled form

24. Bronchodilators—Anticholinergic
Primary use: relief of acute bronchospasm
Sometimes combined with beta-agonists or glucocorticoids
Also prescribed for chronic bronchitis and for symptomatic relief of nasal congestion
Adverse effects: cough, drying of nasal mucosa, hoarseness, bitter taste

25. Anticholinergics
Ipratropium (Atrovent) is the most common anticholinergic prescribed for chronic obstructive pulmonary disease (COPD) and asthma
Most effective when used in combination with beta-agonist
Example: Combivent (ipratropium and albuterol)
Tiotropium is the newest drug in this class

26. Anticholinergic Therapy for Asthma
Assess for history of narrow-angle glaucoma, benign prostatic hyperplasia, renal disorders, urinary bladder neck obstruction
Contraindicated in clients with history of these and in elderly

27. Anticholinergic Therapy for Asthma (continued)
Ipratropium not recommended in children younger than 12 years
Tiotropium not recommended in clients younger than 18 years
Anticholinergics not recommended for women who are breast-feeding

28. Methylxanthines Group of bronchodilators related to caffeine
Once mainstay of chronic asthma pharmacotherapy
Example: theophylline
Narrow margin of safety
Interact with numerous drugs

29. Methylxanthines (continued)
Side effects common
Nausea, vomiting, CNS stimulation
Administered by intravenous or oral routes
Primarily used for long-term prophylaxis of asthma that is unresponsive to beta-agonists or glucocorticoids

30. Methylxanthine Therapy for Asthma (continued)
Use caution in elderly clients and children
Not recommended in women who are breast-feeding
Contraindicated with certain conditions
Coronary artery disease, angina pectoris
Severe renal or liver disorders, peptic ulcer
Benign prostatic hyperplasia, diabetes mellitus

31. Mast-Cell Stabilizers
Inhibit mast cells from releasing histamine and other chemical mediators
Are safe for prophylaxis of asthma
Less effective than inhaled glucocorticoids
Ineffective at relieving acute bronchospasm

32. Leukotriene Modifiers
Leukotrienes are mediators of immune response
Involved in allergic and asthmatic reactions
Leukotriene modifiers primarily used for asthma prophylaxis
Reduce inflammatory component of asthma
Oral medication used when persistent asthma not controlled with other drugs

33. Leukotriene Modifiers
Prototype drug: zafirlukast (Accolate)
Mechanism of action: prevents airway edema and inflammation by blocking leukotriene receptors in airways
Primary use: for prophylaxis of persistent, chronic asthma
Adverse effects: headache, nausea, diarrhea

34. Leukotriene Therapy for Asthma
Monitor vital signs
Respiratory and pulse rates, respiratory effort, lung sounds
Skin color, oxygen-saturation level
Monitor CBC and periodic liver-function tests
Closely monitor prothrombin time (PT) and international normalized ratio (INR) in clients taking warfarin (Coumadin)

35. Leukotriene Therapy for Asthma (continued)
Closely monitor phenytoin level with concurrent phenytoin therapy
Reduce theophylline dose; monitor zileuton levels
Assess for signs and symptoms of infection, especially in elderly
Advise clients not to use leukotriene modifiers during acute asthma attack

36. Drugs of Allergic Rhinitis, Cough, and Colds

37. Allergic Rhinitis
Inflammatory disorder of the upper airway, lower airway, and eyes
Symptoms
Sneezing
Rhinorrhea
Pruritus
Nasal congestion
For some people: Conjunctivitis, sinusitis, and asthma 37

38. Allergic Rhinitis Seasonal and perennial
Triggered by airborne allergens
Allergens bind to immunoglobulin E (Ig E) on mast cells
Triggers release of inflammatory mediators
Histamine, leukotrienes, prostaglandins 38

39. Classes of Drugs Used for Allergic Rhinitis
Glucocorticoids (intranasal)
Antihistamines (oral and intranasal)
Sympathomimetics (oral and intranasal) 39

40. Intranasal Glucocorticoids
First choice ‒ most effective for treatment and prevention of rhinitis
Mild adverse effects
Drying of nasal mucosa or sore throat
Epistaxis (nosebleed)
Headache
Rarely, systemic effects (adrenal suppression and slowing of linear pediatric growth) 40

41. Oral Antihistamines For allergic rhinitis
Do not reduce nasal congestion
Most effective if taken prophylactically
Should be taken regularly throughout the allergy season, even when symptoms are absent, to prevent an initial histamine receptor activation
Mild adverse effects: Sedation with first generation (much less with second generation) 41

42. Intranasal Antihistamines: Azelastine & Olopatadine
Indicated for allergic rhinitis in adults and in children over 12 years old
Systemic absorption can be sufficient to cause somnolence
Nosebleeds
Anticholinergic effects
Unpleasant taste 42

43. Intranasal Cromolyn Sodium
Reduces symptoms by suppressing release of histamine and other inflammatory mediators from mast cells
Prophylaxis
Administer before symptoms start
Response develops in 1 to 2 weeks
Minimal adverse reactions: Less than with any other drug for allergic rhinitis 43

44. Sympathomimetics
Reduce nasal congestion (do not reduce rhinorrhea, sneezing, or itching)
Activate alpha1-adrenergic receptors on nasal blood vessels
Adverse effects
Rebound congestion
CNS stimulation
Cardiovascular effects and stroke
Abuse 44

45. Sympathomimetics (Oral/Nasal)
Factors in topical administration
Should not use longer than 5 consecutive days
Drops or sprays
Comparison: Drops versus sprays
Topical agents act more quickly than oral agents and are usually more effective
Oral agents act longer than topical preparations
Systemic effects occur primarily with oral agents; topical agents usually elicit these responses only when dosage is higher than recommended
Rebound congestion is common with prolonged use of topical agents but rare with oral agents 45

46. Sympathomimetics (Oral/Nasal)
Phenylephrine, ephedrine, pseudoephedrine
Antihistamine-sympathomimetic combinations
Ipratropium bromide [Atrovent]
Montelukast [Singulair]
Omalizumab [Xolair] 46

47. cough Antitussives Expectorants Guaifenesin [Mucinex, Humibid]
Drugs that suppress cough
Opioid antitussives
Codeine and hydrocodone
Nonopioid antitussives
Dextromethorphan
Diphenhydramine
Benzonatate
Guaifenesin [Mucinex, Humibid]
Renders cough more productive by stimulating flow of respiratory tract secretions
Higher doses may be effective

48. Mucolytics Hypertonic saline Acetylcysteine
Mucolytics react directly with mucus to make it more watery
High sulfur content, “rotten egg” smell
Can trigger bronchospasm 48

49. Common Cold Acute upper respiratory viral infection
Rhinorrhea, nasal congestion, cough, sneezing, sore throat, headache, hoarseness, malaise, myalgia
Fever common in kids, rare in adults
Self-limited, usually benign
No cure; just treatment of symptoms 49

50. Over-the-Counter (OTC) Cold Remedies
Combination cold remedies usually contain two or more of the following:
Nasal decongestant
Antitussive
Analgesic
Antihistamine (for cholinergic actions)
Caffeine (to offset effect of antihistamine) 50

51. Pediatric OTC Cold Remedies
Use with caution in young children
Avoid OTC cold remedies in children younger than 4 to 6 years
Use only products labeled for pediatric use
Consult a health care professional before giving these drugs to a child
Read all product safety information before dosing
Use the measuring device provided with the product
Discontinue the medicine and seek professional care if the child’s condition worsens or fails to improve
Avoid using antihistamine-containing products to sedate children 51