1. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 36 Bronchodilators and Other Respiratory Drugs

2. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Diseases of the Lower Respiratory Tract  COPD  Asthma  Emphysema  Chronic bronchitis

3. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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 viscid mucus

4. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Bronchial Asthma (cont’d)  Alveolar ducts/alveoli remain open, but airflow to them is obstructed  Symptoms  Wheezing  Difficulty breathing

5. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Asthma Three categories  Allergic  Idiopathic  Mixed allergic-idiopathic

6. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Asthma (cont’d)  Status asthmaticus  Prolonged asthma attack that does not respond to typical drug therapy  May last several minutes to hours  Medical emergency

7. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Chronic Bronchitis  Continuous inflammation of the bronchi and bronchioles  Often occurs as a result of prolonged exposure to bronchial irritants

8. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Emphysema  Air spaces enlarge as a result of the destruction of alveolar walls  The surface area where gas exchange takes place is reduced  Effective respiration is impaired

9. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Drugs Used to Treat Asthma  Long-term control  Antileukotrienes  cromolyn  Inhaled steroids  Long-acting β 2 -agonists  Quick relief  Intravenous systemic corticosteroids  Short-acting inhaled β 2 -agonists

10. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Bronchodilators and Respiratory Drugs  Bronchodilators  β-adrenergic agonists  Xanthine derivatives  Anticholinergics  Antileukotrienes  Corticosteroids

11. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Bronchodilators: β-Agonists  Large group, sympathomimetics  Used during acute phase of asthmatic attacks  Quickly reduce airway constriction and restore normal airflow  Stimulate β 2 -adrenergic receptors throughout the lungs

12. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Bronchodilators: β-Agonists (cont’d) Three types  Nonselective adrenergics  Stimulate α, β 1 (cardiac), and β 2 (respiratory) receptors  Example: epinephrine  Nonselective β-adrenergics  Stimulate both β 1 and β 2 receptors  Example: metaproterenol (Alupent)

13. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Bronchodilators: β-Agonists (cont’d) Three types (cont'd)  Selective β 2 drugs  Stimulate only β 2 receptors  Example: albuterol (Proventil, others)

14. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. β-Agonists: Mechanism of Action  Begins at the specific receptor stimulated  Ends with the dilation of the airways  Activation of β 2 receptors activates cAMP,* which relaxes smooth muscles of the airway and results in bronchial dilation and increased airflow *cAMP = cyclic adenosine monophosphate *cAMP = cyclic adenosine monophosphate

15. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. β-Agonists: Indications  Relief of bronchospasm related to asthma, bronchitis, and other pulmonary diseases  Useful in treatment of acute attacks as well as prevention  Used in hypotension and shock  Used to produce uterine relaxation to prevent premature labor  Hyperkalemia—stimulates potassium to shift into the cell

16. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. β-Agonists: Adverse Effects α-β (epinephrine)  Insomnia  Restlessness  Anorexia  Vascular headache  Hyperglycemia  Tremor  Cardiac stimulation

17. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. β-Agonists: Adverse Effects (cont’d) β 1 and β 2 (metaproterenol)  Cardiac stimulation  Tremor  Anginal pain   Vascular headache   Hypotension

18. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. β-Agonists: Adverse Effects (cont’d) β 2 (albuterol)  Hypotension OR hypertension  Vascular headache  Tremor

19. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications  Encourage patients to take measures that promote a generally good state of health in order to prevent, relieve, or decrease symptoms of COPD  Avoid exposure to conditions that precipitate bronchospasms (allergens, smoking, stress, air pollutants)  Adequate fluid intake  Compliance with medical treatment  Avoid excessive fatigue, heat, extremes in temperature, caffeine

20. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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 OTCs

21. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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 PO 2  Sputum production  Allergies  History of respiratory problems  Other medications

22. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Teach patients to take bronchodilators exactly as prescribed  Ensure that patients know how to use inhalers and MDIs, and have the patients demonstrate use of devices  Monitor for adverse effects

23. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

24. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. β-Agonist Derivatives: Nursing Implications  Albuterol, if used too frequently, loses its β 2 - specific actions at larger doses  As a result, β 1 receptors are stimulated, causing nausea, increased anxiety, palpitations, tremors, and increased heart rate

25. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. β-Agonist Derivatives: Nursing Implications (cont’d)  Patients should take medications exactly as prescribed, with no omissions or double doses  Patients should report insomnia, jitteriness, restlessness, palpitations, chest pain, or any change in symptoms

26. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Inhalers: Patient Education  For any inhaler prescribed, ensure that the patient is able to self-administer the medication  Provide demonstration and return demonstration  Ensure the patient knows the correct time intervals for inhalers  Provide a spacer if the patient has difficulty coordinating breathing with inhaler activation  Ensure that patient knows how to keep track of the number of doses in the inhaler device

27. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

28. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Anticholinergics  ipratropium bromide (Atrovent) and tiotropium (Spiriva)  Slow and prolonged action  Used to prevent bronchoconstriction  NOT used for acute asthma exacerbations!

29. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Anticholinergics (cont’d) Adverse effects:  Dry mouth or throat  Nasal congestion  Heart palpitations  Gastrointestinal distress  Headache  Coughing  Anxiety No known drug interactions

30. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Bronchodilators: Xanthine Derivatives  Plant alkaloids: caffeine, theobromine, and theophylline  Only theophylline is used as a bronchodilator  Synthetic xanthines: aminophylline dyphilline oxtriphylline

31. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Xanthine Derivatives: Mechanism of Action  Increase levels of energy-producing cAMP  This is done competitively inhibiting phosphodiesterase (PDE), the enzyme that breaks down cAMP  Result: decreased cAMP levels, smooth muscle relaxation, bronchodilation, and increased airflow

32. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Xanthine Derivatives: Drug Effects 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)

33. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Xanthine Derivatives: Drug Effect (cont’d)  Cause bronchodilation by relaxing smooth muscles of the airways  Result: relief of bronchospasm and greater airflow into and out of the lungs  Also cause CNS stimulation

34. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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 due to potential for drug interactions and variables related to drug levels in the blood

35. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Xanthine Derivatives: Adverse Effects  Nausea, vomiting, anorexia  Gastroesophageal reflux during sleep  Sinus tachycardia, extrasystole, palpitations, ventricular dysrhythmias  Transient increased urination

36. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Xanthine Derivatives: Nursing Implications  Contraindications: history of PUD or GI disorders  Cautious use: cardiac disease  Timed-release preparations should not be crushed or chewed (causes gastric irritation)

37. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Xanthine Derivatives: Nursing Implications (cont’d)  Report to physician:  Palpitations  Weakness  Convulsions  Nausea  Dizziness  Vomiting  Chest pain

38. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Xanthine Derivatives: Nursing Implications (cont’d)  Be aware of drug interactions with cimetidine, oral contraceptives, allopurinol, certain antibiotics, others

39. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antileukotrienes  Also called leukotriene receptor antagonists (LRTAs)  Newer class of asthma medications

40. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antileukotrienes (cont’d) Currently available drugs  montelukast (Singulair)  zafirlukast (Accolate)  zileuton (Zyflo)

41. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antileukotrienes: 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

42. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antileukotrienes: Mechanism of Action (cont’d)  Antileukotriene drugs 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

43. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antileukotrienes: 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

44. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antileukotrienes: Indications  Prophylaxis and chronic treatment of asthma in adults and children older than age 12  NOT meant for management of acute asthmatic attacks  Montelukast is approved for use in children ages 2 and older, and for treatment of allergic rhinitis

45. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antileukotrienes: Adverse Effects zileutonzafirlukast HeadacheHeadache DyspepsiaNausea NauseaDiarrhea DizzinessLiver dysfunction Insomnia Liver dysfunction  Montelukast has fewer adverse effects

46. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antileukotrienes: Nursing Implications  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

47. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antileukotrienes: Nursing Implications (cont’d)  Check with physician before taking any OTC or prescribed medications—many drug interactions  Assess liver function before beginning therapy  Medications should be taken every night on a continuous schedule, even if symptoms improve

48. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Corticosteroids  Antiinflammatory  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

49. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Corticosteroids: Mechanism of Action  Stabilize membranes of cells that release harmful bronchoconstricting substances  These cells are leukocytes, or white blood cells  Also increase responsiveness of bronchial smooth muscle to β-adrenergic stimulation

50. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Inhaled Corticosteroids  beclomethasone dipropionate (Beclovent, Vanceril)  triamcinolone acetonide (Azmacort)  dexamethasone sodium phosphate (Decadron Phosphate Respihaler)  fluticasone (Flovent, Flonase)  others

51. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Inhaled Corticosteroids: Indications  Treatment of bronchospastic disorders that are not controlled by conventional bronchodilators  NOT considered first-line drugs for management of acute asthmatic attacks or status asthmaticus

52. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Inhaled Corticosteroids: Adverse Effects  Pharyngeal irritation  Coughing  Dry mouth  Oral fungal infections  Systemic effects are rare because of the low doses used for inhalation therapy

53. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Inhaled Corticosteroids: Nursing Implications  Contraindicated in patients with psychosis, fungal infections, AIDS, TB  Teach patients to gargle and rinse the mouth with lukewarm water afterward to prevent the development of oral fungal infections

54. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Inhaled Corticosteroids: Nursing Implications (cont’d)  If a β-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

55. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Inhaled Corticosteroids: Nursing Implications (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