1. Respiratory Medications RT 1

2. Pharmacology The study of substances that interact with living systems through chemical processes Especially by binding to regulatory molecules and activating or inhibiting normal body processes Basically manipulating normal human chemical mechanisms for a desired effect

3. Drug Any substance that interacts with a molecule or protein that plays a regulatory role in living systems. Includes oxygen and other therapeutic gases along with our inhaled aerosolized medications.

4. How we deliver medications Metered Dose inhalers –Portable –Used with holding chamber Dry Powder inhaler –No propellent Aerosol via nebulizer –Given with mask or mouth piece

8. What types of drugs we give Bronchodilators: Relax bronchial smooth muscle, mimic Epinephrine (adrenaline) –Fast acting: Albuterol, Xopenex –Long lasting: Serevent, Foradil

9. What types of drugs we give Bronchodilators: Relax bronchial smooth muscle Other types of bronchodilators: Atrovent: blocks acetylcholine from entering smooth muscle cells Spiriva: Long lasting anti-cholinergic

10. What types of drugs we give Steroids: Prevent inflammatory cell release, changes cell DNA –Advair (Flovent) –Symbicort (Pulmicort) –Qvar –Asmanex

11. Flovent: DPI/MDI. 3 doses. Asmanex: twisthaler, grey or pink depending on dose Qvar: 40/80 ug dose Aerobid is now Aerospan

12. Pulmicort: turbahaler or respules Advair: MDI or DPI, 3 doses, combo drug Symbicort: 2 doses, combo drug

13. What types of drugs we give Mucoactives: Helps to molecularly break up mucus –Mucomyst (pungent odor) –Pulmozyme (used with Cystic Fibrosis)

14. Mucus Production Normal person produces 100 mL of mucus per 24 hour period –Most is reabsorbed back in the bronchial mucosa –10 mL reaches the glottis –Most of this is swallowed Mucus production increases with lung disease

15. What types of drugs we give Anti-asthma: Prevents inflammatory cell release by blocking histamine from mast cells –Intal (cromolyn sodium) MDI –Singulair (pill, RT’s do not typically administer)

16. Definitions Endogenous: Substances made inside body Exogenous: substances made outside the body Hormones: are endogenous drugs Toxin: poisons of biologic origin

17. Definitions Receptors: Specific molecule, usually a protein, that interacts with a specific chemical that then causes a change in the specific molecule, causing a change in regulatory function Lock that a key fits into; ex: Lock receptor and epinephrine the key to opening the lock

18. Definitions Agonist: any drug that binds to a receptor and activates the receptor Drug that fits into a receptor, will then activate and a chemical reaction occurs within the cell. When agonist leaves the binding site it deactivates the receptor.

19. Definitions Antagonist: any drug that binds to a receptor and prevents the activation of the receptor Can be called competitive antagonist; competes with the agonist for binding site.

20. Definitions Absorbed: drug must be able to absorb into the body to work Delivery: Must be able to get to intended site to work; gut, intestines, liver, blood…then to site of action Elimination: drugs must be eliminated at a reasonable rate. Affected by kidney or liver problems

21. Terminology Names of a drug –Chemical name –Generic name (assigned by US Pharmacopoeia) –Proprietary name

22. Drug Name The chemical name is assigned according to rules of nomenclature of chemical compounds The brand name is always capitalized and is selected by the manufacturer. The generic name refers to a common established name irrespective of its manufacturer.

23. Example The chemical name for albuterol sulfate (albuterol sulfate inhalation solution) is α 1 [(tert-butylamino) methyl]-4-hydroxy-m-xylene-α, α'- diol sulfate (2:1) (salt), and its established chemical structure is as follows:

24. Terminology General terms –Action (mode of action, intended drug effect) –Side effect (not intended effect, nausea/tachycardia…) –Half life time required for concentration of a drug in the body to decrease by 50%. Half-life also represents the time necessary to reach steady state or to decline from steady state after a change

25. Terminology General terms –Tolerance decrease in susceptibility to the effects of a drug due to its continued administration. –Tachyphylaxis rapid decrease in response to a drug after administration of a few doses. Initial drug response cannot be restored by an increase in dose –Potentiation The action of a substance, at a dose that does not itself have an adverse action, in enhancing the effect of another substance

26. Terminology General terms –Synergism the interaction of elements that when combined produce a total effect that is greater than the sum of the individual elements, contributions, etc. –Agonist is a chemical that binds to a receptor of a cell and triggers a response by that cell. Agonists often mimic the action of a naturally occurring substance. Whereas an agonist causes an action, an antagonist blocks the action of the agonist and an inverse agonist causes an action opposite to that of the agonist. –Antagonist: blocks reaction of a agonist

27. Phases of Action Pharmaceutical phase –Refers to method by which a drug is administered and the form in which it is administered

29. Routes of Administration Intravenous (IV) (RT will never give IV drugs, most common route of systemic meds) Inhaled (Aerosol) RT route of administration Intramuscular (IM) (includes diabetes meds, vaccines, boosters…) Subcutaneous (SubQ) (Xylocain administration, numbing agent)

30. Routes of Administration Sublingual Rectal Oral (most common route outside of hospital) Topical

31. Pharmacokinetic Phase Describes the time course and disposition of a drug in the body based upon absorption, distribution, metabolism, and elimination and the effects and routes of excretion of the metabolites of the drug

32. Pharmacokinetic Phase Ionized drugs have minimal side effects generally; non-ionized drugs have greater side effects

33. Pharmacodynamic Phase Describes the mechanism of action of a drug (how it actually works in the patients body) Effects are caused by combining a drug with a matching receptor

34. Receptors Adrenergics: –Beta 1 (heart, when stimulated cause contraction, increased HR)---Isoperternal, Epinephrine –Beta 2 (lungs, when stimulated cause dilation)---- Albuterol/Xopenex –Alpha 1 (blood vessels/brain/kidney, when stimulated cause vessel constriction)—Racemic Epinephrine –Alpha 2 (Sphincters, GI tract, inhibits insulin release; stimulation causes constriction) Stimulated by neurotransmitter Epinephrine/ norepinephrine *Stimulation of a receptor= agonist *Blocking of a receptor = antagonist

35. Receptors Cholinergic: –Nicotinic (found in the CNS and the peripheral nervous system. The neuromuscular receptors are found in the neuromuscular junctions of somatic muscles; stimulation of these receptors causes muscular contraction) Blocked with Nicotinic acetylcholine receptors can be blocked by curare; used for anesthesia and mechainical ventilation –Muscarinic (found primarily in lung; G-protein-coupled receptors that activate other ionic channels via a second messenger cascade. sub types; M1-M5) –responds to the binding neurotransmitter acetylcholine

36. Beta Receptors TissueReceptor Subtype Heartbeta 1 Adipose tissuebeta 1 beta 3 ? Vascular Smooth Musclebeta 2 Airway Smooth Musclebeta 2 Kindney-Renin release from JG cells beta 1

37. How Bronchodilators Work Receptor sites –Alpha sites – cause vasoconstriction and vasopressor effects, increasing blood pressure –Beta 1 sites – cause increase in heart rate and myocardial contractility

38. How Bronchodilators Work Receptor sites –Beta 2 sites – cause relaxation of bronchial smooth muscle, stimulate mucociliary activity, and have mild inhibitory effects on inflammatory mediator release

39. Sympathomimetics Neurotransmitters include: –Epinephrine –Norepinephrine –Catecholmines –Dopamine Fight or Flight response allows for: –Bursts of energy –Increased heart rate –Increased blood to brain –Increased Oxygen through BRONCHODILATION

40. Sympathomimetics Sympathomimetic drugs given by aerosol to the lungs MIMIC fight or flight neurotransmitters and cause DIRECT bronchodilation Examples of Sympathomimic bronchodilators: –Fast Acting: Albuterol, Xopenex, Racemic Epinephrine –Long Acting: Serevent, Brovona

41. Sympathomimetics Sympathomimetic drugs can enter the blood stream and also stimulate Beta 1 receptors increasing systemic side effects such as increased HR These drugs are given for patients with reversible airflow obstruction such as Asthma and COPD

42. Parasympatholytic Substances that reduce the activity of the parasympathetic nervous system The PNS is part of the ANS and is often referred as the rest and digest phase. The primary neurotransmitter in this phase is: –Acetycholine (Ach)

43. Parasympatholytic The Ach response causes: –Decrease in HR –Decrease in BP –Skeletal muscle contraction –Bronchial smooth muscle constriction Ach causes: M3 muscarinic receptor reaction in blood vessels, as well as the lungs causing bronchoconstriction. Drugs that are parasympatholytic BLOCK M3 response and thus indirectly allow for bronchodilation

44. Parasympatholytic Examples of Parasympatholytics bronchodilators: –Fast Acting: Atrovent/Atropine –Long Acting: Spiriva –Parasymptholytic bronchodilators are referred to as anticholinergics, they are Ach antagonists –Ach enters bronchial smooth muscle cells through muscanaric receptors –Atrovent works by blocking all M receptors resulting in the formation of Cyclic guanosine monophosphate

45. Nitric Oxide Indicated for the treatment of pulmonary hypertension in neonates Causes relaxation of vascular smooth muscle, producing pulmonary vasodilation

46. Nitric Oxide Contraindicated in neonates with right to left shunts

47. Nitric Oxide Adverse effects –Hypotension –Formation of Methemoglobinia –Withdrawal

48. Exogenous Surfactant Administration Indicated for surfactant deficiency, such as in infant respiratory distress syndrome and following lung lavage

49. Medication frequency BID= twice a dayAd lib= as desired TID= three times a dayQ4PRN= every 4 hours as needed QID= four times a dayQh= every hour QD= once a dayNS= normal saline QS= every shift m.l.= militer Q4=every 4 hoursMg= miligrams Q6= every 6 hoursNPO= nothing per mouth HS= At bed time PRN= AS NEEDED EX: Albuterol 2.5 mg and 2.5 ml NS Q4 and Q2 PRN for wheezing. Oximeter check QS