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Chapter 37
Respiratory Drugs
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2. Diseases of the Lower Respiratory Tract
COPD
Asthma (persistent and present most of the time despite treatment)
Emphysema
Chronic bronchitis
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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
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4. Bronchial Asthma (cont’d)
Alveolar ducts/alveoli remain open, but airflow to them is obstructed
Symptoms
Wheezing
Difficulty breathing
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Asthma
Four categories
Intrinsic (occurring in patients with no history of allergies)
Extrinsic (occurring in patients exposed to a known allergen)
Exercise induced
Drug induced
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Asthma (cont’d)
Status asthmaticus
Prolonged asthma attack that does not respond to typical drug therapy
May last several minutes to hours
Medical emergency
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Chronic Bronchitis
Continuous inflammation and low-grade infection of the bronchi
Excessive secretion of mucus and certain pathologic changes in the bronchial structure
Often occurs as a result of prolonged exposure to bronchial irritants
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Emphysema
Air spaces enlarge as a result of the destruction of alveolar walls
Caused by the effect of proteolytic enzymes released from leukocytes in response to alveolar inflammation
The surface area where gas exchange takes place is reduced
Effective respiration is impaired
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10. Pharmacologic Overview
Bronchodilators
These drugs relax bronchial smooth muscle, which causes dilation of the bronchi and bronchioles that are narrowed as a result of the disease process
Three classes: beta-adrenergic agonists, anticholinergics, and xanthine derivatives
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11. Bronchodilators: Beta-Adrenergic Agonists
Short-acting beta agonist (SABA) inhalers
albuterol (Ventolin)
levalbuterol (Xopenex)
pirbuterol (Maxair)
terbutaline (Brethine)
metaproterenol (Alupent)
Long-acting beta agonist (LABA) inhalers
arformoterol (Brovana)
formoterol (Foradil, Perforomist)
salmeterol (Serevent)
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12. Bronchodilators: Beta-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
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13. Bronchodilators: Beta-Adrenergic Agonists (cont’d)
Three types
Nonselective adrenergics
Stimulate alpha, beta1 (cardiac), and beta2 (respiratory) receptors
Example: epinephrine
Nonselective beta-adrenergics
Stimulate both beta1 and beta2 receptors
Example: metaproterenol (Alupent)
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14. Bronchodilators: Beta-Adrenergic Agonists (cont’d)
Three types (cont’d)
Selective beta2 drugs
Stimulate only beta2 receptors
Example: albuterol (Proventil, others)
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15. Beta-Adrenergic Agonists: Mechanism of Action
Begins at the specific receptor stimulated
Ends with dilation of the airways
Activation of beta2 receptors activates cyclic adenosine monophosphate (cAMP), which relaxes smooth muscle in the airway and results in bronchial dilation and increased airflow
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16. Beta-Adrenergic Agonists: Indications
Relief of bronchospasm related to asthma, bronchitis, and other pulmonary diseases
Used in treatment and prevention of acute attacks
Used in hypotension and shock
Used to produce uterine relaxation to prevent premature labor
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17. Beta-Adrenergic Agonists: Adverse Effects
Alpha and beta (epinephrine)
Insomnia
Restlessness
Anorexia
Vascular headache
Hyperglycemia
Tremor
Cardiac stimulation
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18. Beta-Adrenergic Agonists: Adverse Effects (cont’d)
Beta1 and beta2 (metaproterenol)
Cardiac stimulation
Tremor
Anginal pain
Vascular headache
Hypotension
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19. Beta-Adrenergic Agonists: Adverse Effects (cont’d)
Beta2 (albuterol)
Hypotension OR hypertension
Vascular headache
Tremor
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Anticholinergics
Ipratropium bromide (Atrovent) and tiotropium (Spiriva)
Slow and prolonged action
Used to prevent bronchoconstriction
NOT used for acute asthma exacerbations!
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21. 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
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22. Anticholinergics: Adverse Effects
Dry mouth or throat
Nasal congestion
Heart palpitations
Gastrointestinal distress
Headache
Coughing
Anxiety
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Xanthine Derivatives
Plant alkaloids: caffeine, theobromine, and theophylline
Only theophylline is used as a bronchodilator
Synthetic xanthines: aminophylline and dyphilline
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24. Xanthine Derivatives: Mechanism of Action
Increase levels of energy-producing cAMP
This is done by competitively inhibiting phosphodiesterase (PDE), the enzyme that breaks down cAMP
Result: decreased cAMP levels, smooth muscle relaxation, bronchodilation, and increased airflow
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25. Xanthine Derivatives: Drug Effects
Cause bronchodilation by relaxing smooth muscle in the airways
Result: relief of bronchospasm and greater airflow into and out of the lungs
Also cause CNS stimulation
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26. Xanthine Derivatives: Drug Effects (cont’d)
Also cause cardiovascular stimulation: increased force of contraction and increased heart rate, resulting in increased cardiac output and increased blood flow to the kidneys (diuretic effect)
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27. Xanthine Derivatives: Indications
Dilation of airways in asthmas, chronic bronchitis, and emphysema
Mild to moderate cases of acute asthma
Adjunct drug in the management of COPD
Not used as frequently because of potential for drug interactions and variables related to drug levels in the blood
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28. Xanthine Derivatives: Adverse Effects
Nausea, vomiting, anorexia
Gastroesophageal reflux during sleep
Sinus tachycardia, extrasystole, palpitations, ventricular dysrhythmias
Transient increased urination
Hyperglycemia
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29. Leukotriene Receptor Antagonists (LTRAs)
Nonbronchodilating
Newer class of asthma medications
Currently available drugs
montelukast (Singulair)
zafirlukast (Accolate)
zileuton (Zyflo)
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30. LTRAs: Mechanism of Action
Leukotrienes are substances released when a trigger, such as cat hair or dust, starts a series of chemical reactions in the body
Leukotrienes cause inflammation, bronchoconstriction, and mucus production
Result: coughing, wheezing, shortness of breath
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31. LTRAs: Mechanism of Action (cont’d)
LRTAs prevent leukotrienes from attaching to receptors on cells in the lungs and in circulation
Inflammation in the lungs is blocked, and asthma symptoms are relieved
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LTRAs: 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
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LTRAs: Indications
Prophylaxis and long-term treatment and prevention of asthma in adults and children 12 years of age and older
NOT meant for management of acute asthmatic attacks
Montelukast is also approved for treatment of allergic rhinitis
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34. LTRAs: Adverse Effects
zileuton
Headache, nausea, dizziness, insomnia, liver function
zafirlukast
Headache, nausea, diarrhea, liver function
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Corticosteroids
Antiinflammatory properties
Used for chronic asthma
Do not relieve symptoms of acute asthmatic attacks
Oral or inhaled forms
Inhaled forms reduce systemic effects
May take several weeks before full effects are seen
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36. Corticosteroids: Mechanism of Action
Stabilize membranes of cells that release harmful bronchoconstricting substances
These cells are called leukocytes, or white blood cells
Increase responsiveness of bronchial smooth muscle to beta-adrenergic stimulation
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37. Inhaled Corticosteroids
beclomethasone dipropionate (Beclovent)
budesonide (Pulmicort Turbuhaler)
dexamethasone sodium phosphate (Decadron Phosphate Respihaler)
flunisolide (AeroBid)
fluticasone (Flonase)
triamcinolone acetonide (Azmacort)
ciclesonide (Omnaris)
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38. Inhaled Corticosteroids: Indications
Persistent asthma
Often used concurrently with beta-adrenergic agonists
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39. Inhaled Corticosteroids: Adverse Effects
Pharyngeal irritation
Coughing
Dry mouth
Oral fungal infections
Systemic effects are rare because low doses are used for inhalation therapy
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40. Phosphodiesterase-4 Inhibitor
roflumilast (Daliresp)
Indicated to prevent coughing and excess mucus from worsening and to decrease the frequency of life-threatening COPD exacerbations
Adverse effects include nausea, diarrhea, headache, insomnia, dizziness, weight loss, and psychiatric symptoms
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41. Monoclonial Antibody Antiasthmatic
omalizumab (Xolair)
Selectively binds to the immunoglobulin IgE, 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
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Nursing Implications
Encourage patients to take measures that promote a generally good state of health so as to prevent, relieve, or decrease symptoms of COPD
Avoid exposure to conditions that precipitate bronchospasm (allergens, smoking, stress, air pollutants)
Adequate fluid intake
Compliance with medical treatment
Avoid excessive fatigue, heat, extremes in temperature, caffeine
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43. Nursing Implications (cont’d)
Encourage patients to get prompt treatment for flu or other illnesses, and to get vaccinated against pneumonia or flu
Encourage patients to always check with their physician before taking any other medication, including over-the-counter medications
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44. Nursing Implications (cont’d)
Perform a thorough assessment before beginning therapy, including:
Skin color
Baseline vital signs
Respirations (should be between 12 and 24 breaths/min)
Respiratory assessment, including pulse oximetry
Sputum production
Allergies
History of respiratory problems
Other medications
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45. Nursing Implications (cont’d)
Teach patients to take bronchodilators exactly as prescribed
Ensure that patients know how to use inhalers and MDIs, and have patients demonstrate use of the devices
Monitor for adverse effects
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46. Classroom Response Question
Which medication will the nurse teach a patient with asthma to use when experiencing an acute asthma attack?
albuterol (Ventolin)
salmeterol (Serevent)
theophylline (Theo-Dur)
montelukast (Singulair)
Correct answer: A
Rationale: Albuterol (Ventolin) is a short-acting bronchodilator (SABA). Patients must be taught to use the SABAs as rescue treatment. Salmeterol (Serevent) is a long-acting bronchodilator. Because the LABAs have a longer onset of action, they must never be used for acute treatment . Because of their relatively slow onset of action, xanthines such as theophylline (Theo-Dur) are more often used for the prevention of asthmatic symptoms than for the relief of acute asthma attacks. Montelukast (Singulair) is an LTRA and is used primarily for oral prophylaxis and long-term treatment of asthma.
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47. Nursing Implications (cont’d)
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
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48. Nursing Implications: Beta-Adrenergic Agonists
Albuterol, if used too frequently, loses its beta2-specific actions at larger doses
As a result, beta1 receptors are stimulated, causing nausea, increased anxiety, palpitations, tremors, and increased heart rate
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49. Nursing Implications: Beta-Adrenergic Agonists (cont’d)
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
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50. Classroom Response Question
A patient with chronic bronchitis calls the office for a refill of his albuterol inhaler. He just had the prescription filled 2 weeks ago, but he says it is empty. When asked, he 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?
The nurse should confirm the pharmacy location for the needed refill.
The nurse should ask the patient to come to the office for an evaluation of his respiratory status.
The nurse should tell the patient not to use this drug too often.
The nurse should consult the prescriber for a different inhaler prescription.
Correct answer: B
Rationale: While it is true that the patient should be reminded about the correct use of this inhaler, it is evident that he has used it too often and that his respiratory status should be evaluated to see if an adjustment in the prescription should be made.
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51. Nursing Implications: Xanthine Derivatives
Contraindications: history of PUD or GI disorders
Cautious use: cardiac disease
Timed-release preparations should not be crushed or chewed (cause gastric irritation)
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52. Nursing Implications: Xanthine Derivatives (cont’d)
Report to prescriber:
Nausea
Vomiting
Restlessness
Insomnia
Irritability
Tremors
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53. Nursing Implications: Xanthine Derivatives (cont’d)
Be aware of drug interactions with cimetidine, oral contraceptives, allopurinol, certain antibiotics, influenza vaccine, others
Cigarette smoking enhances xanthine metabolism
Interacting foods include charcoal-broiled, high-protein, and low-carbohydrate foods
These foods may reduce serum levels of xanthines through various metabolic mechanisms
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54. Nursing Implications: LTRAs
Ensure that the drug is being used for chronic management of asthma, not acute asthma
Teach the patient the purpose of the therapy
Improvement should be seen in about 1 week
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55. Nursing Implications: LTRAs (cont’d)
Advise patients to check with prescriber before taking over-the-counter or prescribed medications to determine drug interactions
Assess liver function before beginning therapy and throughout
Teach patient to take medications every night on a continuous schedule, even if symptoms improve
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56. Nursing Implications: Inhaled Corticosteroids
Teach patients to gargle and rinse the mouth with lukewarm water afterward to prevent the development of oral fungal infections
If a beta-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
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57. Nursing Implications: Inhaled Corticosteroids (cont’d)
Teach patients to monitor disease with a peak flow meter
Encourage use of a spacer device to ensure successful inhalations
Teach patient how to keep inhalers and nebulizer equipment clean after uses
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58. Inhalers: Patient Education
For any inhaler prescribed, ensure that the patient is able to self-administer the medication
Provide demonstration and 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
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59. Classroom Response Question
A patient is prescribed two different types of inhaled medications for treatment of chronic obstructive pulmonary disease (COPD). After administering the first medication, how long should the nurse wait to administer the second medication?
One minute
Five minutes
Ten minutes
Fifteen minutes
Correct answer: B
Rationale: If a second puff of the same drug is ordered, instruct the patient to wait 1 to 2 minutes between puffs. If a second type of inhaled drug is ordered, instruct the patient wait 2 to 5 minutes between the medications or to take as prescribed. Bronchodilators are usually administered first.
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Case Study
The nurse is providing teaching to a group of individuals with chronic obstructive pulmonary disease (COPD) at a community center. Which statement by one of the attendees indicates that further teaching is needed?
“If I develop a puffy face, I will stop taking methylprednisolone (Medrol) immediately.”
“I will inform my prescriber of any weight gain of 2 pounds or more in 24 hours or 5 pounds or more in 1 week.”
“I use omalizumab (Xolair) to control my asthma but not for an acute asthma attack.”
“When taking theophylline (Theo-Dur), I will advise my prescriber if I experience epigastric pain.”
Correct answer: A
Rationale: Patients should be taught to not stop systemic corticosteroids abruptly. The patient should be educated about the possibility of Addisonian crisis, which may occur if a systemic corticosteroid is abruptly discontinued. These drugs require weaning prior to discontinuation of the medication. Patients should monitor their weight daily and report the increase stated. Omalizumab (Xolair) is used for the treatment of moderate to severe asthma and not for aborting acute asthma attacks. Adverse effects of theophylline (Theo-Dur) that should be reported immediately to the prescriber include epigastric pain.
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Case Study
One of the attendees expresses concern regarding her granddaughter’s asthma. The attendee tells the nurse that she is afraid that she will not know which of her granddaughter's medications to give first in case of an asthma attack. Which medication should the nurse inform the attendee to administer first for an acute asthma attack?
ipratropium (Atrovent)
albuterol (Proventil)
budesonide (Pulmicort Turbuhaler)
montelukast (Singulair)
Correct answer: B
Rationale: Albuterol (Proventil) is a short-acting beta2 agonist indicated for treatment of acute asthma attacks. Ipratropium (Atrovent) is an anticholinergic not indicated for treatment of acute asthma attacks. Budesonide (Pulmicort Turbuhaler) is an inhaled corticosteroid that should not be used in an acute asthma attack. Montelukast (Singulair) is a leukotriene receptor agonist used for long-term management of asthma, not for acute exacerbations.
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62. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
One of the attendees tells the nurse that he has asthma and is being treated with a short-acting inhaled beta2 agonist. The nurse identifies this treatment as which step of the stepwise therapy for the treatment of asthma?
Step 1
Step 2
Step 3
Step 4
Correct answer: A
Rationale: Step 1 includes use of a short-acting inhaled beta2 agonist as needed.
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