1. Gas Exchange and Oxygenation: The Upper Respiratory System

2. The Respiratory System

3. Respiratory systems is divided into two functional Systems: 1
Respiratory systems is divided into two functional Systems: 1. Upper Respiratory Tract nares, nasal cavity, pharynx and larynx 2. Lower Respiratory Tract trachea, bronchi, bronchioles, alveoli, and alveolar-capillary membrane

4. Oxygenation Ventilation – movement of air to the alveoli.
A mechanical action
Respiration – gas exchange at the alveolar-capillary membrane
Perfusion – blood flow at the alveoli-capillary bed. Affected by lung pressure and resistance, edema, secretions and bronchospasm.
Diffusion – movement of oxygen into capillaries and carbon dioxide out of the blood.

5. Gas Exchange
Gas exchange is the process by which oxygen is transported to cells and carbon dioxide is transported from cells.
Impairment of gas exchange occurs when the diffusion of gases (oxygen and carbon dioxide) are affected by:
Ineffective ventilation
Reduced capacity for gas transportation (reduced hemoglobin and/or red blood cells), e.g. blood loss or anemia
Inadequate perfusion

6. Risk Factors for Impaired Gas Exchange
Presence of chronic medical conditions, such as:
chronic obstructive pulmonary disease (COPD),
emphysema
cystic fibrosis (CF),
heart Failure (HF)
Age
Smoking
Immunosuppression
Reduced state of cognition
Brain injury
Prolonged immobility

7. Pathophysiology: Upper Respiratory System
Common cold is a viral infection that starts in the upper respiratory tract, sometimes spreading to the lower structures.
Allergic or seasonal rhinitis occurs when the upper airways respond to a specific allergen.
Sinusitis occurs when the epithelial lining of the sinus cavities becomes inflamed. It can be caused by bacteria or viruses.
Pharyngitis is an inflammation or infection of the pharynx.
Laryngitis is an inflammation of the larynx.
Influenza is an infection caused by any of several strains of myxo-viruses.

8. Upper Respiratory System

9. Drug Classifications for Upper Respiratory Disease
Antitussives
Antihistamines
Decongestants
Expectorants
Mucolytics
Anti-inflammatories

10. Antitussive Drugs Prototype drug: dextromethorphan (Robitussin DM)
Antitussives are drugs that suppress the cough reflex.
Many disorders of the upper and lower respiratory tracts are accompanied by an uncomfortable, nonproductive cough.
Coughing normally is a protective mechanism that forces foreign irritants out of the respiratory system, opening it for more efficient flow of air.
Prototype drug:
dextromethorphan
(Robitussin DM)

11. Dextromethorphan: Core Drug Knowledge
Pharmacotherapeutics
Chronic nonproductive cough
Pharmacokinetics
Administered: oral. Metabolism: liver. Excreted: kidneys.
Pharmacodynamics
Directly affects the cough center in the medulla in the brain (CNS effect)
Chemically related to the opiate agonists and can suppress coughing as effectively as narcotics.

12. Dextromethorphan: Core Drug Knowledge (cont.)
Contraindications and precautions
Chronic coughs resulting from emphysema and asthma
Side effects
Nausea, vomiting, drowsiness, dizziness, irritability, and restlessness
Adverse effects
Poor respiratory clearance due to cough suppression effect

13. Dextromethorphan: Teaching, Assessment, and Evaluation
Patient and family education
Emphasize that sedation, drowsiness, and impaired orientation can occur.
Advise not to drive or operate heavy equipment.
Caution patients who are taking certain antidepressants.
Ongoing assessment and evaluation
Monitor the effect of dextromethorphan on the patient’s motor control, sedation, and respiratory status.

14. Discussion Question
Would an antitussive be a good idea for a patient with severe lower respiratory disease, such as emphysema?
Why or why not?

15. Decongestant Drugs Prototype drugs: pseudoephedrine (Sudafed)
Decongestants are drugs taken to decrease nasal congestion, a condition that is caused by an inflammatory response in the upper respiratory tract.
Nasal decongestants work by constricting the nasal arterioles, thereby decreasing the swelling of the nasal membrane.
These drugs can be administered orally
or topically.
Prototype drugs:
pseudoephedrine (Sudafed)
Phenylephrine (Neo-Synephrine)

16. Pseudoephedrine: Core Drug Knowledge
Pharmacotherapeutics
Reduces the volume of nasal mucus and is recommended for the temporary relief of nasal congestion
Pharmacokinetics
Administered: oral. Metabolism: liver. Excreted: kidneys. Onset: 30 minutes.
Pharmacodynamics
Causes vasoconstriction in the nasal mucous membranes

17. Pseudoephedrine: Core Drug Knowledge (cont.)
Contraindications and precautions
Caution with pregnancy and lactation
Adverse effects
Tension, anxiety, restlessness, tremor, insomnia, and weakness
Maximizing therapeutic effects
Encourage patients to use a humidifier, drink plenty of fluids, and avoid smoke-filled rooms.
Minimizing adverse effects
Provide the patient with appropriate safety measures.

18. Pseudoephedrine: Teaching, Assessment, and Evaluation
Patient and family education
Explain to patients that the purpose of the drug is to promote breathing and relieve congestion.
Caution patients to avoid using other OTC drugs.
Ongoing assessment and evaluation
Monitor patients receiving pseudoephedrine for rebound congestion, sedation, dizziness, insomnia, weakness, tremor, and urinary retention.

19. Discussion Questions
What else do you know about pseudoephedrine (Sudafed)?
It’s access is controlled as it is a main ingredient in the illegal manufacture of methamphetamine.
“Extra credit”: What herbal remedy is related to pseudoephedrine?
Ma Huang, which is now banned due to deaths in athletes from cardiac arrest.

20. Decongestants: Phenylephrine
Phenylephrine (Neo-Synephrine) usually used in nasal spray form to treat allergic or nonallergic rhinities by relieving nasal stuffiness and as a decongestant for sinusitis and the common cold
Pharmacodynamics
stimulates alpha-1 adrenergic receptors in the sinuses causing reduction in inflammation of the nasal membranes

21. Decongestants: Phenylephrine
Contraindicated
Chronic rhinitis and caution in hypertension or coronary artery disease
Adverse Reactions
CNS Stimulation – agitation, nervousness, unease
Vasoconstriction
Rebound nasal congestion develops very quickly
Minimizing Adverse Effects
Do not use nasal spray more than 3-5 days
Taper use by alternating nostrils every other day

22. Nasal Glucocorticoids: Mometasone
Mometasone (Nasonex) are given by nasal spray
Pharmacotherapeutics
Used to decrease the inflammation associated with allergic rhinitis by reducing: sneezing, nasal itching, and runny nose.
Adverse Effects
Sore throat, nosebleed, headache, burning in the nose
Minimizing Adverse Effects/Patient Education
Administer daily – not PRN
It may take up to 7 days to reach desired effects

23. Antihistamines Prototype drug: Loratadine (Claritin)
Antihistamines are used to relieve symptoms of allergies.
These drugs block the action of histamine as it is released during the inflammatory response to an antigen.
Effective for allergic rhinitis.
Their action restores normal airflow through the upper respiratory system.
Prototype drug: Loratadine (Claritin)
or fexofenadine (Allegra)

24. Loratadine: Core Drug Knowledge
Pharmacotherapeutics
Relieves symptoms associated with seasonal and perennial allergies
Pharmacodynamics
Selectively blocks the effects of histamine at H1-receptor sites
Contraindications and precautions
Hypersensitivity
Adverse effects
Nausea, drowsiness, dyspepsia, and fatigue

25. Loratadine : Nursing Diagnoses and Outcomes
Risk for Injury caused by drowsiness and fatigue related to drug-induced CNS effects
Patient and family education
Caution patients to take the drug as prescribed.
Tell patients to avoid the use of other OTC drugs.

26. Expectorant Drugs Prototype drug: guaifenesin
Expectorants are drugs that liquefy lower respiratory tract secretions.
This effect decreases the viscosity of the secretions and improves airflow.
Expectorants are available in many OTC preparations.
Prototype drug:
guaifenesin

27. Guaifenesin: Core Drug Knowledge
Pharmacotherapeutics
Relieves dry, nonproductive cough
Pharmacodynamics
Enhances the output of respiratory tract fluids by reducing the adhesiveness and surface tension of the fluids
Contraindications and precautions
Known allergy to medication
Adverse effects
GI symptoms, headache, and dizziness

28. Guaifenesin: Patient Education
Maximizing therapeutic effects
Teach the patient about good pulmonary hygiene, which includes coughing, using deep breathing, drinking plenty of fluids, and using a humidifier.
Minimizing adverse effects
Suggest that the patient eats small, frequent meals to alleviate GI upset.
Guaifenesin should only be used for one week.

29. Mucolytic Drugs Prototype drug: acetylcysteine (Mucomyst)
Mucolytics break down mucus.
The drugs can be administered by a nebulizer or by direct instillation into the trachea.
Mucolytics usually are reserved for patients who have major difficulty mobilizing and coughing up secretions.
Prototype drug: acetylcysteine (Mucomyst)

30. Acetylcysteine: Core Drug Knowledge
Pharmacotherapeutics
Used to liquefy the thick, tenacious secretions.
Pharmacodynamics
It splits disulfide bonds that are responsible for holding the mucous material together.
Contraindications and precautions
Hypersensitive
Adverse effects
Bronchospasm, bronchoconstriction, chest tightness, a burning feeling in the upper airway, and rhinorrhea
Unpleasant (sulfur, rotten egg) smell with

31. Acetylcysteine: Planning and Interventions
Maximizing therapeutic effects
Administer an inhaled beta-agonist before administering acetylcysteine.
Minimizing adverse effects
Inform the patient that nebulization may produce an initially disagreeable odor, but that this odor is transient.

32. Drug + Effect Matching
Loosens/thins secretions Rebound nasal congestion Suppresses mucous production due to anticholinergic effects Central nervous system suppression of cough reflex Allergic rhinitis Sympathetic nervous system stimulation
Phenylephrine Acetylcysteine Mometasone Pseudoephedrine Dextromethorphan Loratadine

33. NCLEX-Style Question #1

34. NCLEX-Style Question #2

35. NCLEX-Style Question #3

36. NCLEX-Style Question #4

37. Answers to NCLEX-Style Questions
1. B 2. B 3. C 4. A

38. Case Study: The Common Cold
Erika Adams, age 22, comes to the nurse-run clinic at the university with complaints of a cold and flu-like symptoms. She states that her cough is keeping her up at night.
Data obtained from the nursing assessment include the following:
Complaints of fatigue, body aches, cough, nasal congestion, and mild fever
Vital signs: temperature, 99.1°F; pulse, 90; respiration, 20; blood pressure, 98/68
Harsh nonproductive cough noted.

39. Case Study: The Common Cold
You suggest comfort measures, including rest and increased fluids, a steam vaporizer.
The patient’s recommended medications include the use of pseudoephedrine, 30 to 60 mg PO every 4 to 6 hours PRN; and dextromethorphan, 30 mg PO every 4 to 8 hours PRN.

40. Case Study: The Common Cold
How do these drugs work together to address Erika’s underlying pathologic conditions?
What other medications may have been considered for treating Erika’s symptoms?
Which findings might demonstrate possible adverse effects from drug therapy?
What teaching is required for Erika regarding her drug therapy?