Drug Classes Asthma Management Quick-Relief Short-acting beta2-adrenergic agonists (SABA) Bronchodilators Choice drug for acute sx Anticholinergics

ergics Bronchodilators Alternate drug for those who CANNOT tolerate SABAs Corticosteroids: systemic Anti-Inflammatory Not rapid acting The physiology of the respiratory system involves two main processes: perfusion and ventilation. Perfusion is the blood flow through the lungs, which allows for gas exchange across the capillaries. Ventilation is the process of moving air into and out of the lungs. The airway diameter is regulated by the autonomic nervous system, which can cause the airway to dilate or constrict.

Asthma is a chronic disease that has both inflammatory and bronchospasm components. The inflammatory component of asthma involves an increase in airway edema coupled with increased mucus secretions that contribute to airway obstruction. Bronchospasm may be induced by various triggers. Acute dyspnea and wheezing are common signs of asthma. Drugs are used to prevent asthmatic attacks and to terminate an attack in progress.

Inhalation is a common route of administration for pulmonary drugs because it delivers drugs directly to the sites of action. The inhalation route is used to deliver medications directly and safely to the respiratory system. Aerosol medications are those delivered as very small liquid droplets or fine, dry particles. Nebulizers, MDIs, and DPIs are types of devices used for aerosol therapies.

The goals of asthma pharmacotherapy are to terminate acute bronchospasms and to reduce the frequency of asthma attacks. National Asthma Education and Prevention (NAEPP) guidelines are used in asthma management. These guidelines initiate therapy in a stepwise approach based on the severity of asthma symptoms. The goals of asthma therapy are to terminate acute bronchospasms and to prevent asthma attacks. Medications used in asthma management are classified as quick-relief agents or long-term control agents.

Beta2-adrenergic agonists are the most effective drugs for relieving acute bronchospasm. Beta agonists activate beta2 receptors in bronchial smooth muscle to cause bronchodilation. The short-acting beta agonists have a rapid onset of action and are used to terminate acute bronchospasm. The long-acting beta agonists are prescribed for asthma prophylaxis, usually when corticosteroids fail to achieve symptom control.

The inhaled anticholinergics are used for preventing bronchospasm. Ipratropium and tiotropium act by blocking cholinergic receptors in bronchial smooth muscle. Ipratropium is used as an alternative drug for asthma prophylaxis and intranasally as a decongestant. Tiotropium is used to prevent bronchospasm in patients with chronic bronchitis or emphysema.

Inhaled corticosteroids are the most effective drugs for the long-term control of asthma. Corticosteroids are the most potent natural anti-inflammatory substances known. Inhaled corticosteroids are the drugs of choice for the prevention of asthmatic attacks and the management of chronic asthma. Oral corticosteroids may be used for the short-term management of acute asthma exacerbations.

Mast cell stabilizers are used for the prophylaxis of asthma and act by preventing the release of histamine. Mast cells contain inflammatory granules, such as histamine, that mediate inflammatory and allergic reactions. When these cells are sensitized, they release the inflammatory substances into the body where they initiate an inflammatory response. Mast cell stabilizers are considered alternate drugs for the prophylaxis of mild to moderate asthma symptoms.

The leukotriene modifiers, which are primarily used for asthma prophylaxis, act by reducing the inflammatory component of asthma. Leukotriene modifiers are medications that reduce inflammation and are considered alternate drugs in the prophylaxis of persistent asthma. Zileuton acts by blocking lipoxygenase, the enzyme that controls leukotriene synthesis. Montelukast and zafirlukast block leukotriene receptors. They are not considered bronchodilators, although they do reduce bronchoconstriction indirectly.

Methylxanthines were once the mainstay of asthma pharmacotherapy but are now rarely prescribed for that disorder. Methylxanthines such as theophylline are less effective, have a narrow therapeutic index, and produce more adverse effects than the beta agonists. They are primarily reserved for the long-term management of persistent asthma that is unresponsive to beta agonists or inhaled corticosteroids.

Monoclonal antibodies are a newer form of therapy for the prevention of asthma symptoms. Omalizumab is the only biologic therapy for asthma management. The drug binds to IgE, preventing the release of chemical mediators of inflammation. It is used for treating moderate to severe, persistent asthma that cannot be controlled with inhaled corticosteroids.

Chronic obstructive pulmonary disease (COPD) may be treated with bronchodilators, anti-inflammatory agents, and mucolytics. COPD is a progressive disorder characterized by chronic and recurrent obstruction of airflow. The two most common conditions that cause chronic pulmonary obstruction are chronic bronchitis and emphysema. The goals of the pharmacotherapy of COPD are to relieve symptoms and avoid complications of the condition. Multiple

pulmonary drugs such as bronchodilators, anti-inflammatory agents, expectorants, mucolytics, antibiotics, and oxygen may offer symptomatic relief.

Causes of bronchial asthma-Bronchospmasma, Inflammation, Edema, Viscid mucus Bronchial asthma -Alveolar ducts/alveoli are open but airflow to them is obstructed Status asthmaticus -^^^^^^^^DOES NOT respond to typical drug therapy

Emphysema -^^^^^^^^Air spaces enlarge bc of alveolar wall destruction Reduced gas exchange area

Long term asthma tx (3) -Leukotriene receptor antagonists, Inhaled steroids, Long-acting beta2-agonists

Quick relief asthma tx (2) -IV corticosteroids, Short-acting inhaled beta2-agonists

Bronchodilator drug types (2) -Beta-adrenergic agonists, Xanthine derivatives

Beta-agonists -ACUTE asthma attacks, Smooth muscle relaxation,Airway dilation

Sympathomimetics

Beta-agonist types (3) -Non-selective adrenergics, Non-selective beta-adrenergics, Selective beta2 drugs

Non-selective adrenergics (2) -^^^^^^^^Beta-agonists

Stimulate alpha, beta1, beta2

Epinephrine (Adrenalin) Ephedrine

Non-selective beta-adrenergics (1) -^^^^^^^^Beta-agonists

Stimulates beta1 and beta2

Metaproterenol (Alupent, Metaprel)

Selective beta2 drugs (5 -rols & 1 weirdo) -^^^^^^^^Beta-agonists, Stimulates beta2 ONLY

Albuterol (Proventil, Ventolin) Formoterol (Foradil, Perforomist) Levalbuterol (Xopenex) Pirbuterol (Maxair) Salmeterol (Serevent) Terbutaline (Brethine)

Beta-agonists: indications -^^^^^^^^Bronchospasm r/t asthma, bronchitis Prevent ACUTE attacks Hypotension Shock Uterine relaxation to prevent early labor

Non-selective adrenergics: AEs -^^^^^^^^Cardiac stimulation Tremor Vascular headache Insomnia Restlessness Anorexia Hyperglycemia

Non-selective beta-adrenergics: AEs -^^^^^^^^Cardiac stimulation

Tremor Vascular headache Anginal pain Hypotension

Selective Beta2 drugs: AEs -^^^^^^^^Tremor Vascular headache Hypo- OR Hypertension

Beta-agonists: implications -^^^^^^^^Avoid conditions that cause bronchospasm Fluids! Compliance AVOID excessive fatigue, extreme temps, & caffeine Get prompt tx for flu and other illnesses Assessment Take as prescribed

Beta-agonists: therapeutic effects -^^^^^^^^Decreased dyspnea Decreased wheezing, restlessness, & anxiety Better respiratory patterns Better activity tolerance Increased ease of breathing

Beta-agonists: assessment -^^^^^^^^Skin color Baseline vitals RR O2 sat Sputum production Allergies History of resp issues

Albuterol -^^^^^^^^Proventil

Selective beta 2 beta-agonist

PC: C

AEs: nausea, anxiety, palpitations, tremors, increased HR

Loses beta2-specific actions if used too much

Salmeterol -^^^^^^^^Serevent

Selective beta 2 beta-agonist

Long-acting NOT for ACUTE asthma

Anticholinergics -^^^^^^^^Slow, prolonged action

Bind to ACh receptors & PREVENT bronchoconstriction Bronchodilation NOT for ACUTE asthma

Ipratropium bromide (Atrovent) Tiotropium (Spiriva)

Anticholinergics: implications -^^^^^^^^ALLERGY to peanuts, soybeans, or other legumes Force fluids!

Ipatropium bromide -^^^^^^^^Atrovent

Anticholinergic

Tiotropium -^^^^^^^^Spiriva

Anticholinergic

Once-daily dosing

Anticholinergics: AEs -^^^^^^^^Dry mouth/throat Nasal congestion Palpitations GI distress Headache Coughing Anxiety

Xanthine Derivatives -^^^^^^^^Bronchodilators

Smooth muscle relaxation Bronchodilation Increased airflow

Plant alkaloids - theophylline*, caffeine, theobromine

Synthetic - aminophylline, dyphilline

Xanthine derivatives: drug effects -^^^^^^^^CV stimulation Increased force of contraction Increased HR Increased CO Increased blood flow to kidneys (diuretic) CNS stimulation

Xanthine derivatives: indications -^^^^^^^^Asthma, bronchitis, & emphysema Mild/moderate ACUTE asthma COPD mgmt

Xanthine derivatives: AEs -^^^^^^^^ANV GER during sleep Tachycardia Extrasystole Palpitations Ventricular dysrhythmias Increased urination

Xanthine derivatives: implications -^^^^^^^^CIs: history of PUD CAUTION: cardiac disease

Timed-release NOT used with GI issues DO NOT use with St. John's Wort Low-carb, high-protein, charcoaled meats, & smoking decrease THEOPHYLLINE levels AVOID caffeine bc exacerbates CNS stimulation IVs not too fast bc can cause hypotension, tachy, seizures, & cardiac arrest

Xanthine derivatives: REPORT... -^^^^^^^^Chest pain Palpitations Weakness Convulsions NV Dizziness

Xanthine derivatives: interactions -^^^^^^^^Cimetidine Oral contraceptives Allopurinol Macrolide antibiotics Quinolones Flu vaccine

INCREASE xanthine levels

Theophylline -^^^^^^^^Theo-Dur, Elixophyllin

Xanthine derivative

PC: C

Leukotreine receptor antagonist drugs (LTRAs) (3) -^^^^^^^^Montelukast (Singulair) Zafirlukast (Accolate) Zileuton (Zyflo)

LTRAs -^^^^^^^^Leukotrines cause inflammation, bronchoconstriction, & mucus

LRTAs prevent leukotrines from binding to receptors Relieve asthma symptoms Decrease neutrophil & leukocyte infiltration

LRTAs: indications -^^^^^^^^Prophylaxis & chronic asthma NOT for ACUTE asthma attacks

Montelukast -^^^^^^^^Singulair

LRTA

PC: B

Allergic rhinitis OK for kids 2 & up AEs: fewer than other LRTAs

Zileuton AEs -^^^^^^^^Zyflo

LRTA

AEs: headache, dyspepsia, nausea, dizziness, insomnia, liver dysfunction

Zafirlukast -^^^^^^^^Accolate

LRTA

AEs: headache, ND, liver dysfunction

LRTAs: implications -^^^^^^^^CHRONIC asthma Give at NIGHT Improvement should be within 1 week Assess liver function Continuous schedule even if symptoms improve

Corticosteroids -^^^^^^^^Anti-inflammatory effects Increase response of smooth muscle to Beta-adrenergics

CHRONIC asthma DOES NOT help ACUTE asthma

Oral & inhaled forms Inhaled reduces systemic effects

May take weeks to see effects

Inhaled corticosteroids (6) -^^^^^^^^Beclomethasone diproprionate (Beclovent, Vanceril) Triamcinolone acetonide (Azmacort) Dexamethasone sodium phosphate (Decadron Phosphate Respihaler) Fluticasone (Flonase, Flovent) Budesonide (Pulmocort Turbuhaler) Flunisolide (AeroBid)

Inhaled corticosteroids: indications -^^^^^^^^Bronchospastic disorders not controlled by normal bronchodilators

NOT first-line for ACUTE asthma attacks or status asthmaticus

Inhaled corticosteroids: AEs -^^^^^^^^Pharyngeal irritation Coughing Dry mouth Oral funal infections Rare systemic effects bc low doses

Inhaled corticosteroids: implications -^^^^^^^^CIs: psychosis, fungal infections, AIDS, TB Must be weaned slowly bc can increase BG levels Can slow bone growth in kids Gargle and rise with lukewarm water Bronchodilator before corticosteroid Teach pts about peak flow meter Encourage spacer to ensure successful inhalations Teach how to clean equipment

Fluticasone proprionate -^^^^^^^^(Flonase, Flovent)

Corticosteroid

PC: C

Methylprednisolone -^^^^^^^^(Medrol, Solu-Medrol)

Corticosteroid

PC: C

Omalizumab -^^^^^^^^(Xolair)

Monoclonal antibody antiasthmatic

Binds IgE

AEs: hypersensitivity reactions

Allergen -^^^^^^^^a substance capable of producing an allergic reaction.

Angioedema -^^^^^^^^edema and swelling beneath the skin.

Antiallergic -^^^^^^^^drug that prevents mast cells from relaeasing histamine and other vasoactive substances.

Antibody -^^^^^^^^a specialized protein (immunoglobulin) that recognizes the antigen that triggered its production.

Antigen -^^^^^^^^substance, usually protein or carbohydrate, that is capable of stimulating an immune response.

Antihistaminic -^^^^^^^^drug that blocks the action of histamine at the target organ.

Asthma -^^^^^^^^inflammation of the bronchioles associated with constriction of smooth muscle, wheezing, and edema.

Dermatitis -^^^^^^^^inflammatory condition of the skin associated with itching, burning, and edematous vesicular formations.

Eczematoid Dermatitis -^^^^^^^^condition in which lessons on the skin ooze and develop scaly crusts.

Erythema -^^^^^^^^redness of the skin, often a result of capillary dilation

Excoriation -^^^^^^^^an abrasion of the epidermis (skin) usually from a mechanical (not chemical) cause, a scartch.

Histamine -^^^^^^^^substance that interacts with tissues to produce most of the symptoms of allergy.

Hives -^^^^^^^^a skin condition characterized by intensely itching wheals caused by an allergic reaction; also called urticaria

Hyperemia -^^^^^^^^increased blood flow to a body part like the eye; engorgement.

Nonselective -^^^^^^^^interacts with any subtype receptor.

Prophylactic -^^^^^^^^process or drug that prevents the onset of symptoms (or disease) as a result of exposure before the reactive process can take place.

Selective -^^^^^^^^interacts with one subtype of receptor over others.

Sensitize -^^^^^^^^to induce or develop a reaction to naturally occuring substances (allergens) as a result of repeated exposure.

Urticaria -^^^^^^^^intensely itching raised areas of skin caused by an allergic reaction; hives.

Wheal -^^^^^^^^a firm, elevated swelling of the skin often pale red in color and itchy; a sign of allergy.

Xerostomia -^^^^^^^^dryness of the oral cavity resulting from inhibition of the natural moistening action of salivary gland secretions or increased secretion of salivary mucus, rather than serous material.

Bronchodilator -^^^^^^^^drug that relaxes bronchial smooth muscle and dilates the lower respiratory passages.

Chemical Mediator -^^^^^^^^substance released from mast cells and white blood cells during inflammatory and allergic reactions.

Chronic Bronchitis -^^^^^^^^respiratory condition caused by chronic irration that increasessecretion of mucus and causes degeneration of the respiratory lining.

COPD -^^^^^^^^Chronic Obstructive Pulmonary Diesase, usually caused by emphysema and chronic bronchitis.

Emphysema -^^^^^^^^disease process causing destruction of the walls of the alveoli

Expectorant -^^^^^^^^drug that helps clear the lungs of respiratory secretions.

Leukotrienes -^^^^^^^^chemical mediators involved in inflammation and asthma.

Mucolytic -^^^^^^^^drug that liquefies bronchial secretions.

Prostaglandins -^^^^^^^^chemical mediators released from mast and other cells involved in inflammatory and allergic conditions.

Abortifacient -^^^^^^^^substance that induces abortion.

Absorption -^^^^^^^^the uptake of nutrients from the GI tract.

Acid Rebound -^^^^^^^^effect in which a great volume of acid is secreted by the stomach in response to the reduced acid environment caused by antacidneutralization.

Antacid -^^^^^^^^drug that neutralizes hydrochloric acid (HCI) secreted by stomach.

Antisecretory -^^^^^^^^substance that inhibits secretion of digestive enzymes, hormones, or acid.

Chyme -^^^^^^^^partially digested food and gastric secretions that move into the stomach by peristalsis.

Digestion -^^^^^^^^mechanical and chemical breakdown of foods into smaller units.

Dyspepsia -^^^^^^^^indigestion.

Emesis -^^^^^^^^vomiting.

Enterochromaffin-Like Cells (ECL) -^^^^^^^^celsl that synthesize and release histamine.

GERD -^^^^^^^^gastroesphageal refluex disease.

Heartburn (Acid Indigestion) -^^^^^^^^a painful burning feeling behindthe sternum that occurs when stomach and backs up into the esophagus.

Heaptic Microsomal Metabolism -^^^^^^^^specific enzymes in the liver (p450 family) that meabolize somedrugs and can be increased (stimulated) by some medications or decreased (inhibited) by other medications so that therapeutic drug blood levels are altered.

Hyperacidity -^^^^^^^^abnormally highdegree of acidity (for example, pH less than 1) in the stomach.

Hypercalcemia -^^^^^^^^elevated concentration of calcium ions in the circulating blood.

Hyperchlorhydria -^^^^^^^^excess hydrochloricacid in the stomach.

Hypermotility -^^^^^^^^increase in muscle tone or contractions causing faster clearance ofsubstances through the GI tract.

Hypophosphatemia -^^^^^^^^abnormally low concentrations of phosphate in thecirculating blood.

Parietal (Oxyntic) Cell -^^^^^^^^cell that synthesizes and releases hydrocholoric acid (HCI) into thestomach lumen.

Pepsin -^^^^^^^^enzyme that digests protein in the stomach.

Perforation -^^^^^^^^opening in a hollow organ, such as a break in the intestinal wall.

Proteolytic -^^^^^^^^action that causes the decomposition or destruction of proteins.

Ulcer -^^^^^^^^open sore in the mucous membranes or mucosal linings of the body.

Ulcerogenic -^^^^^^^^capable of producing minor irritation or lesions to an integral break in the mucosal lining (Ulcer)

Absordent -^^^^^^^^substance that has the ability to attach other substances to its surface.

Cathartic -^^^^^^^^pharmacological substance that stimulates defecation.

Chloride Channel Activators -^^^^^^^^a novel class of drugs that stimulate pare-forming receptors in the intestine, causing chloride ions to cross membranes.

Constipation -^^^^^^^^a decrese in stool frequency.

Defecation -^^^^^^^^process of discharging the contents of the intestines, as feces.

Diarrhea -^^^^^^^^abnormal looseness of the stool or watery stool, which may be accompanied by a change in stool frequency or volume.

Electrolyte -^^^^^^^^ion in solution, such as sodium, potassium, or chloride, that is capable of mediating conduction (passing impulses in the tissues).

Emollient -^^^^^^^^substance that is soothing to mucous membranes or skin.

Evacuation -^^^^^^^^process of removal of waste material from the bowel.

Hernia -^^^^^^^^protusion of an organ through the tissue usually containing it; for example, intestinal tissue pushing outside the abdominal cavity, or stomach, pushing into the diaphragm (hiatal heria).

Hypokalemia -^^^^^^^^decrease in the normal concentration of potassium in the blood.

Hyponatremia -^^^^^^^^decrease in the normal concentration of sodium in the blood.

IBS (Irritable Bowel Syndrome) -^^^^^^^^a functional disorder of the colon with abdominal pain, cramping, bloating, diarrhea, and/or constipation.

Laxative -^^^^^^^^a substance that promotes bowel movements.

Mu-Opioid Receptor Antagonist -^^^^^^^^drugs that block the mu protein receptor for opioids.

Osmolality -^^^^^^^^the concentration of particles dissolved in a fluid.

Osmosis -^^^^^^^^process in which water moves across membranes following the movementof sodium ions.

Peristalsis -^^^^^^^^movement characteristic of the intestines, in which cirular contraction and relaxation propel the contents toward the rectum.

Transit Time -^^^^^^^^amount of time it takes for food to travel from the mouth to the anus.

Acromegaly -^^^^^^^^condition usually in middle-aged adults from hypersecretion of growth hormone.

Carcinoid Tumor -^^^^^^^^a slow-growing type of cancer that can arise in the gastrointestinal tract, lungs, ovaries, and testes.

Cretinism -^^^^^^^^condition in which the development of the body and brain has been inhibited.

Ductless Glands -^^^^^^^^containing no duct; endocrine glands that secrete hormones directly into the blood or lyumph without goingthrough a duct.

Dwarfism -^^^^^^^^inadequate secretion of growth hormone during childhood, characterized by abnormally short statue and normal body proportions.

Endocrine -^^^^^^^^pertaining to gland that secrete substances directly into the blood.

Gigantism -^^^^^^^^increased secretion of growth hormone in childhood, causing excessive growth and height.

Gonads -^^^^^^^^organs that produce male (testes) or female (ovaries) sex cells, sperm, or ova.

Hormone -^^^^^^^^substance produced within one organ and secreted directly into the circulation to exert its effects at a distant location.

Insulin-Like Growth Factor (IGF) -^^^^^^^^stimulator of cell growth and proliferation.

Somatomedins -^^^^^^^^peptides in the plasma that stimulate cellular growth and have insulin-like activity.

Somatostatin -^^^^^^^^an inhibitory hormone that blocks the release of somatotropin (GH) and thyroidstimulating hormone (TSH).

Target Organ -^^^^^^^^specific tissue for growth hormone (GH)

Tropic Hormone -^^^^^^^^hormone secreted by the anterior pituitory that binds to a receptor on another endocrine gland.

Addison's Disease -^^^^^^^^inadequate secretion of gluocoriticoids and mineralcorticoids.

ADT -^^^^^^^^Alternate-Day Therapy.

Catabolism -^^^^^^^^process in which complex compounds are broken down into simpler molecules; usually associated with energy release.

Circadian Rhyrhm -^^^^^^^^internal biological clock; a repeatable 24-hour cycle of physiological activity.

Glucocorticoid -^^^^^^^^steriod produced within the adrenal cortex (or a synthetic drug) that directly influences carbohydrate metabolism and inhibits the inflammatory process.

Gluconeogensis -^^^^^^^^the synthesis of glucose from molecules that are not carbohydrates, such as amino and fatty acids.

Intra-Articular (IA) -^^^^^^^^joint space into which drug is injected.

Isotonic -^^^^^^^^Normal salt concentration of most body fluids; a slat concentration of 0.9 percent.

Lymphokine -^^^^^^^^a substance secreted by T-Cells that signals other immune cells like macrophages to aggregate.

Lyysosome -^^^^^^^^part of a cell that contains enzymes capable of digesting or destroying tissue/proteins.

Mineralocorticoid -^^^^^^^^steroid produced within the adrenal cortex that directly influences sodium and potassium metabolism.

Native -^^^^^^^^natural substance in the body.

Proinflammatory -^^^^^^^^tending to cause inflammation.

Replacement Therapy -^^^^^^^^administration of a naturally occuring substance that the body is not able to produce inadequate amounts to maintain normal function.

Repository Preparation -^^^^^^^^preparation of a drug, usually fro intramusclar or subcutaneous injection, that is intends to leach out from the site of injection slowly so that the duration of drug action is prolonged.

Steroid -^^^^^^^^member of a large family of chemical substances (hormones,drugs) containing a structure similar to cortisone (tetracyclic cyclopenta-a-phenanthrene).

Allegra -^^^^^^^^allergies

Benadryl -^^^^^^^^allergies

Claratin -^^^^^^^^allergies

Zyrtec -^^^^^^^^allergies

Delsym -^^^^^^^^antitussive

Tessalon Pexles -^^^^^^^^antitussive

Tussionex -^^^^^^^^antitussive

Sudafed -^^^^^^^^decongestent

Robitussin -^^^^^^^^expectorant

Atrovent -^^^^^^^^asthma

Proventil -^^^^^^^^asthma

Combivent -^^^^^^^^asthma

Flonasc -^^^^^^^^asthma

What is the first line treatment for asthma, a.k.a. quick relief? -^^^^^^^^short acting agonist (albuterol) anticholinergics (ipratropium) Systemic corticosteroids

What is the second line treatment for asthma, a.k.a. controllers? -^^^^^^^^inhaled corticosteroids (aerobid) long acting agonist (salmeterol) leukotriene receptor antagonists (montelukast)

Theophylline or cromolyn may also be considered

First line: How does the short acting agonist work on the body? -^^^^^^^^-Sympathomimetic that results in smooth airway muscle relaxation -Bronchodilation reduces airway resistance as shown by increased FEV1, mid-expiratory flow rate, and vital capacity -Increased cAMP inhibits the release of mediators from mast cells in the airways, producing a mild antiinflammatory effect

Albuterol - Class -^^^^^^^^short acting agonist

Albuterol - Indication -^^^^^^^^treatment or prevention of bronchospasm in pt's w/ reversible obstructive airway dz; prevention of exercise-induced bronchospasm

Albuterol - MOA -^^^^^^^^relaxes bronchial smooth muscle by action on receptors w/ little effect on HR

Albuterol - Pregnancy -^^^^^^^^Cat C

albuterol is the preferred short acting agonist for use in asthma during pregnancy

Albuterol - Contraindications -^^^^^^^^hypersensitivity

overdose can be fatal! Overdose symptoms may include nervousness, headache, tremor, dry mouth, chest pain or heavy feeling, rapid or uneven heart rate, pain spreading to the arm or shoulder, nausea, sweating, dizziness, seizure (convulsions), feeling light-headed or fainting.

Albuterol - Adverse effects -^^^^^^^^chest pain, palpitations, tremor, nervousness, hypokalemia, BP, HA, dizziness, insomnia, cough, hoarseness, sore throat, runny nose, drymouth & throat, muscle pain, diarrhea.

rarely, paradoxical bronchospasm may occur

Albuterol - Precautions -use w/ caution in pt's with CV dz as agonists can BP, HR, stimulate the CNS, and risk of arrhythmias, *use w/ caution in pt's with DM as agonists can serum glucose, *use w/ caution in pt's with glaucoma as agonists can intraocular pressure use w/ caution in pt's with hyperthyroidism as agonists can thyroid activity use w/ caution in pt's with hypokalemia as agonists can serum K use w/ caution in pt's with seizure disorders as agonists can stimulate the CNS *Albuterol - Metabolism & Excretion -Metabolism: liver extensively; Excretion: urine primarily, feces; Half-life: 2.7-6h first line: how do anticholinergic bronchodilators work on the body? -block the nerve responses (parasympathetic) that normally cause narrowing of airways. commonly used in combination with a beta 2 bronchodilator such as albuterol* blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscle causing bronchodilation* ipratropium (atrovent)* drug of choice for beta-blocker induced bronchospasms*ok for pregnant women suffering w/ severe asthma exacerbations*hypersensitivity to ipratropium or atropine*adverse effects -uri, bronchitis, sinusitis, cp, palpitations, ha, dizziness, dyspepsia, nausea, uti, back pain, dyspnea, rhinitis, cough, pharyngitis, sputum, flu-like syndrome*rarely, paradoxical bronchospasm may occur*ipratropium (atrovent) - precautions -not for rescue therapy, this med should only be used in acute exacerbations of asthma in conjunction with a short acting agonist fo r acute episodes*use with caution in pt's w/ narrow angle glaucoma, myasthenia gravis, & prostatic hyperplasia/bladder neck obstructions Binds to mast cells and prevents mast cell rupture and degranulation.Binds to receptors on monocytes, eosinophils, epithelial cells and platelets to interfere with the release of inflammatory mediators and cytokines. In managing lower respiratory tract disorders, which main classes of drugs are used*Drugs can be grouped into mucolytic agents, such as acetylcysteine; bronchodilators, such as theophylline; and anti-inflammatory drugs, such as cromolyn sodium. Theophylline acts by stimulating two prostaglandins, which results in smooth-muscle relaxation in both the bronchi and vasculature. Betaadrenergic agonists are sympathomimetic agents. That means the drugs mimic the action of norepinephrine. In the lungs, norepinephrine stimulates bronchodilation. Anticholinergic agents block the action of acetylcysteine. When acetylcysteine stimulates the lungs, bronchoconstriction occurs; thus, when its action is blocked, the bronchi do not constrict. In a patient with acute respiratory distress, which of the bronchodilators would be most effective? Beta-adrenergic agonists, such as albuterol, have the quickest onset of action. They are referred to as rescue drugs. Which of the anti -inflammatory agents is the most effective? Glucocorticosteroids are the most powerful anti-inflammatory agents. What is the difference between glucocorticoid steroids given orally and by inhalation? Both drugs are effective in reducing inflammation. Glucocorticoid steroids given orally have the potential to cause more adverse effects because they are systemic. Steroids given by inhalation have a local action; thus, they cause fewer adverse effects. Cromolyn sodium works by stabilizing the mast cell. When the mast cell ruptures in response to an antigen, bronchoconstrictive substances such as histamine, bradykinin, serotonin, and leukotrienes are released. By stabilizing the mast cell, the drug prevents release of these substances. Glucocorticoid steroids have a multitude of actions. In the lungs, they decrease the effectiveness of inflammatory cells, thus keeping the bronchioles open. Leukotriene antagonists block the ability of leukotrienes to bind to their receptor sites. Because leukotriene binding to these sites is what causes bronchoconstriction, bronchoconstriction is blocked. If a patient is taking inhaled steroids, an anticholinergic inhaler, and a beta-adrenergic agonist inhaler, which inhaler would you tell the patient to use first? The beta-adrenergic agonist inhaler should be used first because it has the fastest onset. It will open the bronchial tree, so that the other drugs can be dispersed farther into the lungs to exert their action.

Ipratropium (Atrovent) - PK/PD -^^^^^^^^Absorption: Mean bioavailability is 7% (inhalation). Ipratropium is not readily absorbed. ok for pregnant women suffering w/ severe asthma exacerbations hypersensitivity to ipratropium or atropine Adverse effects -^^^^^^^^URI, bronchitis, sinusitis, CP, palpitations, HA, dizziness, dyspepsia, nausea, UTI, back pain, dyspnea, rhinitis, cough, pharyngitis, sputum, flu-like syndrome rarely, paradoxical bronchospasm may occur

Ipratropium (Atrovent) - Precautions -^^^^^^^^NOT FOR RESCUE THERAPY. This med should only be used in acute exacerbations of asthma IN CONJUNCTION WITH a short acting agonist for acute episodes

use with caution in pt's w/ narrow angle glaucoma, myasthenia gravis, & prostatic hyperplasia/bladder neck obstructions

Ipratropium (Atrovent) - PK/PD -^^^^^^^^Absorption: Mean bioavailability is 7% (inhalation). Ipratropium is not readily absorbed.

Ipratropium (Atrovent)* Drug of choice for beta-blocker induced bronchospasms

Ipratropium (Atrovent) - Indication -^^^^^^^^anticholinergic bronchodilator used in bronchospasm associated w/ COPD, bronchitis, & emphysema (& asthma exacerbations but is more effective in COPD than asthma)

Drug of choice for beta-blocker induced bronchospasms

Ipratropium (Atrovent) - MOA -^^^^^^^^blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscle causing bronchodilation

Drug of choice for beta-blocker induced bronchospasms

Ipratropium (Atrovent) - Pregnancy -^^^^^^^^Cat B

ok for pregnant women suffering w/ severe asthma exacerbations

Ipratropium (Atrovent) - Contraindications -^^^^^^^^hypersensitivity to ipratropium or atropine

Ipratropium (Atrovent) - Adverse effects -^^^^^^^^URI, bronchitis, sinusitis, CP, palpitations, HA, dizziness, dyspepsia, nausea, UTI, back pain, dyspnea, rhinitis, cough, pharyngitis, sputum, flu-like syndrome

rarely, paradoxical bronchospasm may occur

Ipratropium (Atrovent) - Precautions -^^^^^^^^NOT FOR RESCUE THERAPY. This med should only be used in acute exacerbations of asthma IN CONJUNCTION WITH a short acting agonist for acute episodes

use with caution in pt's w/ narrow angle glaucoma, myasthenia gravis, & prostatic hyperplasia/bladder neck obstructions

Ipratropium (Atrovent) - PK/PD -^^^^^^^^Absorption: Mean bioavailability is 7% (inhalation). Ipratropium is not readily absorbed.

Distribution: 0 to 9% is protein bound.

Metabolism: Partially metabolized.

Excretion: The t is approximately 2 h (inhalation or IV). Following IV administration, approximately half of the dose is excreted unchanged in the urine.

Ipratropium (Atrovent) - Pt education -^^^^^^^^Avoid contact with eyes; may cause temporary blurring of vision

First line: Systemic corticosteroids *prednisone, prednisolone, methylprednisone*Second line: How do inhaled corticosteroids (ICS) work on the body? *reduce airflow obstruction by reducing airway inflammation in the bronchioles*Why would you use ICS? -^^^^^^^^Management of persistent asthma, all severity levels* Most potent /effective controller asthma medicationBroad action on inflammatory processesMDI, DPI, nebulizer solutionImproves symptoms, pulmonary functionReduces exacerbations (urgent visits, emergency care, hospitalizations, quick-relief medications, oral CS)Reduces airway hyperresponsiveness: HPA suppression is noted in adults receiving 32 puffs/day of an inhaled steroid over a period of 1 month - monitor for adrenal insufficiencyInhaled corticosteroids (ICS) provide local therapeutic action with minimal systemic ICS are in both Asthma/COPD and Upper Respiratory Infections

I will only include Flunisolide (Aerobid) here because it is oral. The other five ICS are nasal and I will group them together under URI as it is done on the professor's slides [Budesonide (Rhinocort), Flunisolide (Nasarel), Fluticasone propionate (Flonase), Mometasone furoate (Nasonex), & Triamcinolone acetonide (Nasacort)]

TWO Flunisolides - Aerobid & Nasarel.

Flunisolide (Aerobid) - Class -^^^^^^^^inhaled corticosteroids

Flunisolide (Aerobid) - Indication -^^^^^^^^Long-term prevention of bronchospasm in patients with asthma

Aerobid (flunisolide) Inhaler is indicated in the maintenance treatment of asthma as prophylactic therapy. Aerobid is also indicated for asthma patients who require systemic corticosteroid administration, where adding Aerobid may reduce or eliminate the need for the systemic corticosteroids.

Aerobid Inhaler is NOT indicated for the relief of acute bronchospasm.

Flunisolide (Aerobid) - MOA -^^^^^^^^ inflammation by suppression of migration of polymorphonuclear leukocytes & reversal of capillary permeability; does not depress hypothalamus

Flunisolide (Aerobid) - Pregnancy -^^^^^^^^Cat C

Flunisolide (Aerobid) - Contraindications -^^^^^^^^hypersensitivity

Flunisolide (Aerobid) - Adverse effects -^^^^^^^^n/v/d dyspepsia, flu like symptoms sore throat, HA, nasal congestion, URI, unpleasant taste, palpitations, abd pain, CP, appetite, edema, fever, candida infection, dizziness, nervous,

Flunisolide (Aerobid) - Precautions -^^^^^^^^pts treated w/ Aerobid (flunisolide) should be observed for any systemic corticosteroid effect, including suppression of bone growth in children. Particular care should be taken in post-op pt's or during periods of stress for in adrenal function.

Also safety issues: bone density, bruising

Corticosteroids may mask infection or predispose to infection, especially fungal; subcapsular cataracts; glaucoma; adrenocortical insufficiency; psychic derangements; GI bleeding; diabetes mellitus, reactivation of tuberculosis

Flunisolide (Aerobid) - Pt Education -^^^^^^^^ Rinse mouth after use use at regular intervals for effectiveness do not use as emergency therapy for asthma attacks Do not abruptly stop medication administration Discard canister when doses should have been used; canister cannot be accurately checked

Second line: How do long acting agonists work on the body? -cause relaxation of bronchial smooth muscle. Slowly cleared from body so effects are long lasting (onset of action is also longer). Not used in acute asthma attack*How do long acting agonists and corticosteroids complement each other? -^^^^^^^^Corticosteroids increase b2-receptor synthesis and decrease b2 desensitization*LABAs prime glucocorticoid receptors for steroiddependent activation*Salmeterol (Serevent) - Class -^^^^^^^^long acting agonist*Salmeterol (Serevent) Indication -^^^^^^^^maintenance treatment of asthma & prevention of bronchospasm (as concomitant therapy) in pt's with reversible obstructive airway dz, to include pt's w/ sxs of nocturnal asthma, prevention of exerciseinduced bronchospasm, & maintenance treatment of bronchospasm associated with COPD*Salmeterol (Serevent) - MOA -^^^^^^^^relaxes bronchial smooth muscle by selective action on receptors w/ little effect

on HR; salmeterol acts locally in the lung*Salmeterol (Serevent) - Pregnancy -^^^^^^^^Cat C*-agonists may interfere with uterine contractility if administered during labor - use only if clearly needed.*Salmeterol (Serevent) - Contraindications -^^^^^^^^hypersensitivity*monotherapy! it should never be used alone to treat asthma*Salmeterol (Serevent) - Adverse effects -^^^^^^^^Arrhythmias and/or tachycardia, cardiac arrest, death, headache, hyperglycemia, hypokalemia, muscle cramps, palpitations, prolongation of the QTc interval, tremor rarely, paradoxical bronchospasm may occur*Salmeterol (Serevent) - Precautions -^^^^^^^^When added to usual asthma therapy, there may be an increase in asthma-related deaths. Only use salmeterol as additional therapy for patient not adequately controlled on other asthma-controller medications (eg, low- to medium-dose inhaled corticosteroids) or whose disease severity clearly warrants initiation of treatment with 2 maintenance therapies, including salmeterol - do not use salmeterol as monotherapy.*Salmeterol (Serevent) - Pt education ^^^^^^^^ do not use for acute exacerbations of asthma* NEVER use a spacer device daily use is required to manage sxs do not exceed prescribed does (yes, it DID go into the nose!)*Salmeterol (Serevent) - drug/drug interactions -^^^^^^^^Beta-adrenergic blockers: Pulmonary effects of salmeterol may be blocked and may produce severe bronchospasm in patients with COPD*Diuretics: ECG changes and hypokalemia associated with diuretics may worsen with coadministration*MAOIs, tricyclic antidepressants: May increase CV effects of salmeterol.

Second line: How do leukotriene receptor agonists work on the body? -^^^^^^^^block the production or action of inflammatory mediators called leukotrienes, reducing inflammation and relaxing airway smooth muscle and reducing mucus production*Not used for acute attack*Montelukast sodium (Singulair) - class leukotriene receptor antagonist*Montelukast sodium (Singulair) - indication -^^^^^^^^prophylaxis and chronic treatment of asthma; relief of symptoms of seasonal allergic rhinitis & perennial allergic rhinitis; prevention of exerciseinduced bronchospasm*Montelukast sodium (Singulair) - MOA -^^^^^^^^selective leukotriene receptor antagonist that inhibits the cysteinyl leukotriene receptor (these receptors have been correlated with the pathophys of asthma and allergic rhinitis)* pregnancy -^^^^^^^^Cat B*adverse effects -^^^^^^^^dizziness, fatigue, HA, fever, rash, dyspepsia, dental pain, gastroenteritis, LFTs, weakness, nasal congestion, epistaxis, sinusitis, URI, abd pain, psychomotor hyperactivity, somnolence, thirst, vomiting*Montelukast sodium (Singulair) - precautions -^^^^^^^^will not interrupt the bronchoconstrictor response to ASA or NSAIDs; use caution with those drugs*rarely, can cause systemic eosinophilia and vasculitis or behavorial changes*pt education -^^^^^^^^Advise patient with asthma or asthma and allergic rhinitis to take prescribed dose once daily in the evening - best taken 1 hour before meals or 2 hours after*Caution patient with asthma that medication is not to be used to treat acute asthma attacks. Instruct patient to always have a short-acting betaagonist available for acute treatment of asthma symptoms*May be used as an alternative to inhaled corticosteroids in patients with mild persistent or aspirin-sensitive asthma*Effect is weaker than that of low-dose inhaled corticosteroids*Usually used as add-on therapy in asthma

Why use theophylline or cromolyn? -^^^^^^^^Theophylline may be used either as an adjunctive therapy in conjunction with ICS or as an alternative agent, but is not recommended as a preferred therapy*Cromolyn sodium is an alternative option*What are methylxanthines used for? -^^^^^^^^Cause relaxation of bronchial smooth muscle by blocking action of chemicals that cause contraction. Oral slow release theophylline is used to long term control. They are however irritating to the stomach. Available in IV form for used in acute asthma attack* treatment of symptoms and reversible airway obstruction due to chronic asthma or other chronic lung diseases* Promote bronchodilation by competitively inhibiting phosphodiesterase, the enzyme that degrades cAMP, which in turn, increases intracellular cAMP*Act as a direct central nervous system stimulant, resulting in vasoconstriction and stimulation of the vagal center, which causes bradycardia*In large doses, cause a positive

inotropic effect on myocardium and a positive chronotropic effect on SA node*a mild to moderate bronchodilator used as alternative, not preferred, therapy for step 2 care (for mild persistent asthma) or as adjunctive therapy with ICS in patients > 5 years of age* PregCat C*Contrain-hypersens or allergy to corn as the premixed injection may contain corn-derived dextrose*Adverse eff^vomiting, insomnia, restlessness, seizures, increased heart rate, or a headache* have mild anti-inflammatory effects. Monitoring of serum theophylline concentration is essential* Therapeutic index is low - think toxicity*Monitoring Parameters serum drug levels, q24h during infusion*Many drugs and physiologic variables affect theophylline metabolism, and dosage adjustment is required*Pt ed^Extended-release capsules should be taken 1 hour before or 2 hours after meals; immediate-release forms can be taken with food if GI upset occurs*Dont change brands theophylline w/0 consulting provider*Notify if nausea, vomiting, insomnia, jitteriness, headache, rash, severe GI pain, restlessness, convulsions, or irregular heartbeat occurs*Avoid caffeine-containing beverages and other stimulants

Why use a nonsteroidal antiallergic? -^^^^^^^^to block the release or action of inflammatory chemicals in the body reducing symptoms of inflammation. Block degranulation of the mast cell. Not for acute attack. and for Asthma prophylaxis. Prevention of bronchoconstriction before exposure to a known precipitant

Cromolyn (Intal) - Class -^^^^^^^^nonsteroidal antiallergic - mast cell stabilizer

Note - Cromolyn is another double drug on this test, as Intal here (nebulizer) and later on as NasalCrom (nasal spray)

Cromolyn (Intal) - Indication -^^^^^^^^may be used as an adjunct in the prophylaxis of allergic disorders, including asthma; prevention of exercise-induced bronchospasm

Cromolyn (Intal) - MOA -^^^^^^^^prevents the mast cell release of histamine, leukotrienes, and slow-reacting substance of anaphylaxis by inhibiting degranulation after contact with antigens

Cromolyn (Intal) - Pregnancy -^^^^^^^^Cat B

Cromolyn (Intal) - Contraindications -^^^^^^^^hypersensitivity, acute asthma attacks

Cromolyn (Intal) - Adverse effects -^^^^^^^^Bronchospasm, throat irritation, bad taste, cough, wheezing, nasal congestion, anaphylaxis

Cromolyn (Intal) - Precautions -^^^^^^^^use w/ caution in pt's with a h/o arrhythmias, hepatic or renal impairment

need to be tapered off

now only available in Nebulizer form, the inhalers were discontinued

Cromolyn (Intal) - Pt education -^^^^^^^^take 30 min before meals. clear as much mucus as possible before use. Rinse mouth after use to unpleasant aftertaste.

What drugs are used for mild COPD? -^^^^^^^^short acting agonist

What drugs are used for moderate COPD? -^^^^^^^^in addition to those used in mild dz, add on:

anticholinergic long acting agonist

What drugs are used for severe COPD? -^^^^^^^^in addition to those used in mild & moderate dz, add on:

inhaled corticosteroid

What drugs are used for very severe COPD? -^^^^^^^^in addition to those used in mild, moderate, & severe dz; add on:

O2, consider surgery

What other drug might you consider for COPD? -^^^^^^^^theophylline

Bronchodilators & the older adult -^^^^^^^^Bronchodilators may cause increased adverse reactions; some older adults may not tolerate side effects such as tachycardia

Theophylline & the older adult -^^^^^^^^Theophylline clearance is reduced in the older adult, causing increased risk of drug toxicity and interaction

Corticosteroids & the older adult -^^^^^^^^High-dose inhaled corticosteroids and oral corticosteroids that are often used in COPD may cause or worsen osteoporosis in the older adult

Nebulization & the older adult -^^^^^^^^Nebulization treatment may be useful when older adults are unable to use inhalers correctly

Corticosteroids & pregnancy -^^^^^^^^ICS does not increase the risks of major malformations, preterm delivery, low birth weight, and pregnancy-induced hypertension

Cat B drugs -^^^^^^^^ipratropium, mast cell stabilizers, budesonide, montelukast and zafirlukast, and terbutaline, cromolyn

Cat C drugs -^^^^^^^^-Adrenergic agonists (except terbutaline), theophylline, tiotropium, corticosteroids (except budesonide), zileuton, albuterol, aerobid, salmeterol

Theophylline & breastfeeding -^^^^^^^^Breastfeeding may have to be discontinued because the drug can cause serious toxicity in nursing infants

How do you treat mild, intermittent symptoms of allergic rhinitis? -^^^^^^^^Antihistamine, preferably nonsedating, or a decongestant

If the pt is unable to take an oral antihistamine, consider the use of a nasal antihistamine, intranasal cromolyn, or a leukotriene receptor antagonist

How do you treat moderate, frequent symptoms of allergic rhinitis? -^^^^^^^^Regular- to high-dose intranasal corticosteroid

Add an oral or nasal antihistamine and decongestant if necessary

How do you treat moderate, persistant symptoms of allergic rhinitis? -^^^^^^^^Combination regimen consisting of intranasal corticosteroids plus a nonsedating or intranasal antihistamine and decongestant if necessary

How do you treat severe symptoms of allergic rhinitis? -^^^^^^^^Combination regimen consisting of a nonsedating antihistamine with or without a decongestant and intranasal corticosteroid

Consider the use of an oral steroid for 5 days and the use of oxymetazoline as needed for no longer than 3 days

Which antihistamines are sedating? -^^^^^^^^benadryl, Chlor-Trimeton, ethanolamine: diphenhydramine; clemastine fumarate, alkylamine: chlorpheniramine maleate

Which antihistamines are low-sedating? -^^^^^^^^zyrtec

piperadine: cetirizine HCl

Which antihistamines are nonsedating? -^^^^^^^^allegra, claritin

fexofenadine HCl, loratadine HCl, desloratadine

What are two 1st generation antihistamines that are OTC and on our test? -^^^^^^^^Diphenhydramine (Benadryl) & chlorpheniramine maleate (Chlor-Trimeton)

Diphenhydramine (Benadryl) - Class -^^^^^^^^Histamine H1 Antagonist, first gen ethanolamine derivative

Diphenhydramine (Benadryl) - Indication -^^^^^^^^Symptomatic relief of allergic symptoms caused by histamine release including nasal allergies and allergic dermatosis Adjunct to epinephrine in the treatment of anaphylaxis Nighttime sleep aid Prevention or treatment of motion sickness Antitussive Management of Parkinsonian syndrome including drug-induced extrapyramidal symptoms Topically for relief of pain and itching associated with insect bites, minor cuts and burns, or rashes due to poison ivy, poison oak, and poison sumac

Diphenhydramine (Benadryl) - MOA -^^^^^^^^Competes with histamine for H1-receptor sites on effector cells in the gastrointestinal tract, blood vessels, and respiratory tract; anticholinergic and sedative effects are also seen

Diphenhydramine (Benadryl) - Pregnancy -^^^^^^^^Cat B

some toxicity seen in newborns if mom was taking a lot; not the antihistamine of choice for allergic rhinitis, n, or v in pregnancy

Diphenhydramine (Benadryl) - Contraindications -^^^^^^^^Hypersensitivity; acute asthma; neonates or premature infants; breast-feeding; use as a local anesthetic (injection)

she mentioned breast feeding like 4 times with this one

Diphenhydramine (Benadryl) - Adverse effects -^^^^^^^^sedation, sleepiness, dizzy, n, v, urinary retenion or frequency, thickening of bronchial secretions, stuffiness, anaphylaxis, dry mouth/throat, blurred vision

Diphenhydramine (Benadryl) - Precautions -^^^^^^^^use w/ caution in those that have asthma, CV dz, glaucoma, prostatic hyperplasia/GU obstruction, pyloroduodenal obstruction, or thyroid dysfunction

Diphenhydramine (Benadryl) - PK/PD -^^^^^^^^PK: Onset of action: Maximum sedative effect: 1-3 hours Duration: 4-7 hours Metabolism: Extensively hepatic via CYP2D6; minor CYP1A2, 2C9 and 2C19; smaller degrees in pulmonary and renal systems; significant first-pass effect Bioavailability: Oral: ~40% to 70% Half-life elimination: 2-10 hours; Elderly: 13.5 hours Time to peak, serum: 2-4 hours Excretion: Urine (as unchanged drug

Diphenhydramine (Benadryl) - Pt education -^^^^^^^^Avoid use of other depressants, alcohol, or sleepinducing medications unless approved by prescriber. It may cause drowsiness or dizziness (use caution when driving or need to be alert); or dry mouth, nausea, or vomiting. Report persistent sedation, confusion, or agitation; changes in urinary pattern; blurred vision; sore throat, respiratory difficulty, or expectorating; or lack of improvement or worsening or condition

Chlorpheniramine maleate (Chlor-Trimeton) - Class -^^^^^^^^Histamine H1 Antagonist, first gen alkylamine derivative

Chlorpheniramine maleate (Chlor-Trimeton) - Indication -^^^^^^^^Perennial and seasonal allergic rhinitis and other allergic symptoms including urticaria

Chlorpheniramine maleate (Chlor-Trimeton) - MOA -^^^^^^^^competes w/ histamine for H receptor sites on effector cells in the GI tract, blood vessels, & resp tract

Chlorpheniramine maleate (Chlor-Trimeton) - Pregnancy -^^^^^^^^Cat C

Chlorpheniramine maleate (Chlor-Trimeton) - Contraindications -^^^^^^^^Hypersensitivity to any component of the formulation

Narrow-angle glaucoma bladder neck obstruction or symptomatic prostate hypertrophy during acute asthmatic attacks stenosing peptic ulcer or pyloroduodenal obstruction In elderly pts, the anticholinergic action may cause significant confusional symptoms, constipation, or problems voiding urine.

Chlorpheniramine maleate (Chlor-Trimeton) - Adverse effects -^^^^^^^^drowsiness, thickening of bronchial secretions, HA, dizzy, n, diarrhea, wt gain & appetite increase, urinary retention, diplopia, polyuria, pharyngitis, arthralgia, weakness

Chlorpheniramine maleate (Chlor-Trimeton) - Precautions -^^^^^^^^watch for CNS depression

use w/ caution in those w/ CV dz, intraocular pressure, prostatic hyperplasia/GU obstruction, asthma or chronic breathing disorders, or thyroid dysfunction

Chlorpheniramine maleate (Chlor-Trimeton) - PK/PD -^^^^^^^^PK: Half-life elimination, serum: 20-24 hours Metabolism: Substrate of CYP2D6 (minor), 3A4 (major); Inhibits CYP2D6 (weak)

On to more classes of drugs for allergic rhinitis...

What are some intranasal steroids that will be on the test? -^^^^^^^^Traimcinolone acetonide (Nasacort) Fluticasone propionate (Flonase) Budesonide (Rhinocort) Flunisolide (Nasarel) Mometasone furoate (Nasonex)

And what is an intranasal mast cell stabilizer that will be on the test? -^^^^^^^^Cromolyn sodium (NasalCrom)

this drug was covered above in asthma (Intal the nebulizer) so I'm only going to highlight the differences here (NasalCrom is a nasal spray)

And what is a Leukotriene Receptor Antagonist that will be on the test? -^^^^^^^^montelukast sodium (Singulair)

this was covered above in asthma so I'm not going to do another drug card here as it is in the same form and everything - only major difference is dosing

When should NasalCrom be started? -^^^^^^^^Should be started 3 to 4 weeks before a peak allergy season occurs

What is the effect of NasalCrom on the nose? -^^^^^^^^Their effect on the nose is short acting and makes compliance more difficult in that several doses are needed per day

What should you monitor for with NasalCrom? -^^^^^^^^Instruct patients to notify health care provider of any stinging effect after nasal instillation

Now on to the five intranasal steroids... -^^^^^^^^exciting!!!!!

Intranasal Steroids - Indication -^^^^^^^^Vasomotor rhinitis and relief of symptoms of seasonal or perennial rhinitis when effectiveness of antihistamines or tolerance to treatment develops

Intranasal Steroids - MOA -^^^^^^^^Potent glucocorticoid and weak mineralocorticoid activity Inhibit cells, including mast cells, eosinophils, neutrophils, macrophages, lymphocytes, and mediators such as histamine, leukotrienes, and cytokines Exert direct local antiinflammatory effects with minimal systemic effects Effectively control the four major symptoms of allergic rhinitisrhinorrhea, congestion, sneezing, and nasal itch

Intranasal Steroids - Effectiveness -^^^^^^^^The most effective agents for the management of allergic rhinitis because of their direct reduction of nasal inflammation and their ability to reduce nasal hyperreactivity

Should be used for at least 3-4 weeks before a decision is made as to whether they are effective (1 inhaler)

Can be used with asthmatic patients and with those who have comorbid nasal polyposis. Intranasal steroids may help shrink nasal polyps

Intranasal Steroids - Benefits -^^^^^^^^Relieve sneezing, nasal pruritus, rhinorrhea, and reactive mucosal edema Minimal systemic absorption Effectiveness depends on regular use and adequate nasal airway for delivery Most do not alleviate ocular symptoms

Intranasal Steroids - Common concerns -^^^^^^^^Steroid phobia Aversion of nasal sprays (Discomfort, Addiction) Local irritation, mucosal changes; nosebleeds Cataracts, glaucoma (STUDY CONCLUSION: No increase risk of cataract in patients taking INS)

Intranasal Steroids - Pt education -^^^^^^^^Use patient information provided with product on how to use nebulizer, inhaler Do not exceed recommended dosage Clear secretions from nasal passages before using; use decongestants if necessary Effects are not immediate; results require regular use and may take up to 7 days

Intranasal Steroids - Side effects -^^^^^^^^Pharyngitis, epistaxis, cough, headache, weakness, tired feeling, nausea, loss of appetite, weight loss; fever, chills, body aches, flu symptoms; easy bruising or bleeding, unusual weakness; white patches or sores inside your nose or mouth, or on your lips; or blurred vision, eye pain, or seeing halos around lights

Intranasal Steroids - Precautions -^^^^^^^^avoid in pts w/ adrenal suppression, delayed wound healing, immunosupression, infections, or ocular dz

especially in nasal infection, trauma, or s/p nasal surgery

Intranasal Steroids - Pregnancy -^^^^^^^^Cat B - budesonide

Cat C - flunisolide, fluticasone, triamcinolone, mometasone

Intranasal Steroids - Dosing differences -^^^^^^^^once a day spray - budesonide, fluticasone, triamcinolone, mometasone

twice a day (or more) spray - flunisolide

Intranasal Steroids - differences -^^^^^^^^there aren't a lot of differences. I highly suspect this is one of those "which one is safe for pregnant women?" ones - which would be budesonide (Rhinocort)

Ipratropium (Atrovent) -^^^^^^^^Decongestent, Anticholinergic For conditions needing bronchodilation Inhibits PSNS controlled bronchoconstriction

Fluticasone (Flonase or Flovent) -^^^^^^^^Decongestent, Corticosteriod For Asthma, and Bronchitis Uses:Antiinflammatory

H1 Receptors -^^^^^^^^mediate smooth muscle contraction and dilate capillaries. *Lungs

H2 receptors -^^^^^^^^mediate heart acceleration and gastric acid secretion *Bowel/intestines

Histamine -^^^^^^^^chemical alarm signal released by mast cells that causes blood vessels to dilate during an inflammatory response

Antitussives -^^^^^^^^relieve or suppress coughing

Codeine -^^^^^^^^Antitussive, Narcotic Used for: cough supression, inhibits ciliary action.

Detromethorphan (Robitussin DM) -^^^^^^^^Antitussives, Non-Narcotic Used for: cough supression, acts directly on the cough center to suppress cough. do NOT inhibit ciliary action. DONT TAKE W/- MAO's or SSRI's

Guiafenesin (Mucinex) -^^^^^^^^Respiratory Expectorants Used for: nonproductive cough to stimulate the resp. tract.

Fexofenadine (Allegra) -^^^^^^^^Antihistamine H1 Blocker. Used for: allergic rhinitis, allergy symptoms Bind to H1 receptors to block histamine effects. Pregnancy Cat: C

Asthma -^^^^^^^^condition w/ sensitive airways causing bronchoconstriction.

Extrinsic Asthma -^^^^^^^^due to factors outside the body like allergens or air pollution

Intrinsic Asthma -^^^^^^^^idiopathic asthma; attacks are usually triggered by infections, respiratory irritants, cold air, exercise, stress

Mixed Asthma -^^^^^^^^Mixture of intrinsic and extrinsic factors, triggers, and effect

Methylxanthines (Theophylline) -^^^^^^^^Bronchodilator-- long term control Used for: reversible bronchoconstriction, asthma, bronchitis, some emphysema. Inhibits phosphodiesterase which allows cyclic AMP to breakdown. Also decreases MAST cell mediator release to helps prevent mucus build up Therapeutic level is 10-20mcg/ml smokers need increased doses. Take w/ water to decrease GI upset

Albuterol (Proventil) B2 Selective -^^^^^^^^Bronchodilator--Sympathomimetic Beta Agonist FAST ACTING RESCUE INHALER ^ flight or fight. Used for: Acute bronchospasm Teach use of MDI (metered dose inhalers) wait 10-15 sec. between puffs.

Montelukast (Singulair) Zileuton (Zyflo) Zarirlukast (Accolate) -^^^^^^^^Antileukotrienes-- Leutotriene Receptor Antagonsists (LTRA's) Prophylaxes and treatment for chronic asthma in adults and kids 2+years. NOT for acute attacks. Long term control.

Metered-Dose Inhaler -^^^^^^^^Press canister toward mouthpeice to deliver measured dose or puff of medication.

Dry powder inhaler -^^^^^^^^Activated when the patient inhales through the mouthpiece, delivers a fine dry powder. Timing of drug delivery and inhalation doesn't matter

Nebulizer -^^^^^^^^Machine that delivers a fine mist through a face mask or other hand-held device. Takes approx 30 min for treatment.

Rebound Effect -^^^^^^^^Excessive use of nasal decongestants can lead to greater congestion b/c of __________?

Antihistamines -^^^^^^^^block the release or action of histamine

Drugs for COPD -^^^^^^^^includes: Bronchodilators,inhaled steroids, Leukotriene receptor blockers and other anti-asthma drugs

Decongestants -^^^^^^^^utilized to decrease the blood flow to the upper respiratory tract and decrease the excessive production of secretions

Expectorants -^^^^^^^^used to decrease the viscosity of sputum to produce effective cough

Anti-Histamine contraindications -^^^^^^^^CNS-drowsiness, and sedation Fatigue Anticholinergic effects Skin dryness

Rhinitis -^^^^^^^^inflammation of the mucous membrane of the nose

Xanthines Pharmacodynamics/contraindications -^^^^^^^^Stimulate the CNS such that respiration is stimulated. CNS effects, cardiac arrhythmias, gi upset, local irriation

Aerosol -^^^^^^^^Suspension of minute liquid droplets or fine solid particles in a gas.

Allergen -^^^^^^^^...

Allergic rhinitis -^^^^^^^^...

Asthma -^^^^^^^^Chronic inflammatory disease of the lungs characterized by airway obstruction.

Bronchospasm -^^^^^^^^Rapid constriction of the airways.

Chronic bronchitis -^^^^^^^^Recurrent disease of the lungs characterized by excess mucus production, inflammation, and coughing.

Chronic obstructive pulmonary disease (COPD) -^^^^^^^^Generic term used to describe several pulmonary conditions characterized by cough, mucus production, and impaired gas exchange.

Dry powder inhaler (DPI) -^^^^^^^^Device used to convert a solid drug to a fine powder for the purpose of inhalation.

Emphysema -^^^^^^^^Terminal lung disease characterized by permanent dilation of the alveoli.

H1 receptor -^^^^^^^^Site located on smooth muscle cells in the bronchial tree and blood vessels that is stimulated by histamine to produce bronchodilation and vasodilation.

H2 receptor -^^^^^^^^Site located on cells of the digestive system that is stimulated by histamine to produce gastric acid.

Histamine -^^^^^^^^Chemical released by mast cells in response to an antigen that causes dilation of blood vessels, bronchoconstriction, tissue swelling, and itching.

Leukotrienes -^^^^^^^^Chemical mediator of inflammation stored and released by mast cells; effects are similar to those of histamine.

Mast cells -^^^^^^^^Connective tissue cell located in tissue spaces that releases histamine following injury.

Metered dose inhaler (MDI) -^^^^^^^^Device used to deliver a precise amount of drug to the respiratory system.

Nebulizer -^^^^^^^^Device used to convert liquid drugs into a fine mist for the purpose of inhalation.

Perfusion -^^^^^^^^Blood flow through a tissue or organ.

Rebound congestion -^^^^^^^^...

Respiration -^^^^^^^^Exchange of oxygen and carbon dioxide in the lungs; also, the process of deriving energy from metabolic reactions.

Ventilation -^^^^^^^^Process by which air is moved into and out of the lungs.

Repiratory center is the ... -^^^^^^^^medulla oblongata

Process of gas exchange is called -^^^^^^^^respiration

Process of ventilation is.. -^^^^^^^^mechanical

V/Q ratio is ... -^^^^^^^^the amount of air reaching the alveoli to the amount of blood reaching the alveoli; should be about .95-1

Airway is the size of your ... -^^^^^^^^pinky

Inadequate ventilation/Oxygen means .... -^^^^^^^^increased airway resistance(swelling/mucus/ decreased ciliary action/bronchospasms) Loss of elastic recoil of lungs(emphysema, cystic fibrosis)

Emphysema causes your alveoli to... -^^^^^^^^puff up, and become destroyed due to air being trapped and lung size increase

Pink puffers is a condition of... -^^^^^^^^emphysema

Asthma is also called... -^^^^^^^^airway reactive disorder

Asthma is either ... -^^^^^^^^intrinsic- non-allergic; infection or exercised induced Extrinsic- allergy/hypersensitive; Ab/allergen rxn; mucus, swelling, bronchoconstriction

In an extrinsic rxn, Ab attach to ... cells, which rupture and release ..., and slow reacting substance of anaphylaxis(SRS-A) -^^^^^^^^mast;histamine

Drug administration for lung problems can be.. -^^^^^^^^oral, IV, nasal spray, inhalant(Metered Dose Inhaler), inhalation

Inhaled drugs were known by ancient civilizations, current smokers, and drug abusers to... -^^^^^^^^act quickly, min. dose required, non-invasive

Scientists discovered that inhalants... -^^^^^^^^goes directly into lungs, min. side effects, avoids hepatic first pass, systemic absorbed

Metered dose inhalers are... -^^^^^^^^advantages: portable, cheap Disadvantages: don't take it right

How you use inhalers is .... -^^^^^^^^shake, take deep breath while inhaling, wait 30 seconds, then rinse mouth(thrush/bacterial/yeast infection if don't)

Spacer is used if can't... -^^^^^^^^hold breath

What are the disadvantages/advantages of dry powder? -^^^^^^^^Advantages= no propellant, just inhale Disadvantages= bulky, limited doses, expensive, don't know when you are out

Nebulizer's advantages/disadvantages are? -^^^^^^^^Advantages= for children/elderly/emrgency; drug nebulized into a mist; breath normally Disadvantages=bulky, inconvenient, expensive, long tx time(10-15min), drug packaging varies, need power source

Antitussive is a .. -^^^^^^^^cough suppressant

Cough center is in the ... -^^^^^^^^medulla

Antitussive medicines.. -^^^^^^^^depress cough center in medulla; cause post nasal drip

Some antitussive drugs are... -^^^^^^^^narcotics: codeine, hydrocodone; in tablets or syrup; cause drowsiness Non-narcotics: dextromethorphan, Robutussin-DM, Benylin

Benzonatate(Tessalon) is similar to...Side effects are... -^^^^^^^^local anesthetic, anesthetizing stretch receptors in lungs(if receptors aren't stretch, then can't cough; rash, increased secretion, sedation, nausea, paradoxical excitement

Some long acting antitussive medications are... -^^^^^^^^whiskey+lemon+honey and wild cherry

Halls menthalarem cause ... because cause post nasal drip... -^^^^^^^^cough

Expectorant is.... -^^^^^^^^sputum

Antitussive agents ... -^^^^^^^^promote the cough, or smoothing action on mucosa by increasing amount if liquid in repiratory tract (i.e Robutussin-stimulate secretions)

Antihistimines .... -^^^^^^^^dry you up; blocks effects of histamine(runny nose, congestion, allergic reaction, itching, motion sickness; side effects are sedation, dry mouth, urinary hesitency(anticholinergic)

Antihistimines also can cause an ....... attack, increase ..., increase blood pressure, and may trigger ... storm, increase ... pressure and photosensitivity, increase risk for seizures (avoid driving). ^^^^^^^^asthma;HR;Thyroid(too much); intraocular

Mucolytic's do what... -^^^^^^^^lysis tenacious secretion; some side effects are bronchospasms, smells like rotton eggs

Some mucolytic drugs are... -^^^^^^^^acetylcysteine-liquefies

Some nursing considerations of antitussives are... -^^^^^^^^adequate fluid intake(except milk); liquid cough medicine; Head above body when sleep; note color, consistency of sputum, avoid caffeine

Inflammatory cell(mast cell) stabilizer's .... -^^^^^^^^work on mast/macrophage/neutrophils/eosinophils cell's to prevent release of histamines; not antihistamines; give before exercising, running

Some Inflammatory cell stabilizer medicines are... -^^^^^^^^cromolyn sodium(Ital); have short half life

Antiinflammatory leukotriene receptor antagonist drugs are... -^^^^^^^^zafir lukast(accolate) or monte lukast (Singular); promotes bronchorelaxation, improves wheezing, coughing, dyspnea, decrease inflammation; slow acting and po; side effects are headache, nausea/vomiting

Corticosteroids... -^^^^^^^^decrease inflammation and edema; side effects are hoarseness, oral candida infection(suppress normal flora of mouth); must observe mouth for thrush

Some corticosteroid medications are -^^^^^^^^beclomethasone(Beclovert) and fluticasone propionate(Flonase), and prednisone given typically via inhalation and intranasal

Singular with inhaled steroid provides... -^^^^^^^^better control of inflammation becuase inhaled steroid can't formation of cysteinyl leukotrienes

Non-selective Bronchodilators are.. -^^^^^^^^sympathamimic; epinephrine(potent);Vaponephrine(racemic epinephrine); Medhale-Epi; Primatine mist(OTC);Pseudoephedrine(sudafed)

Selective bronchodilators(Beta2 agonists) are... -^^^^^^^^albutrol(ventolin) po inhalation; metroproternol(Alupent) po inhalation; terbutaline(Brethine) po injection, inhalation[preterm labor relaxes bronch]; side effects are palpitation, tachycardia, headache, flushing, nausea, hypertension, anxiety, tremor

Anticholinergic bronchodilators are... -^^^^^^^^ipothropiaum bromide(atrovent); stops bronchoconstriction; side effects are glaucoma, cough, hoarseness, irritation, dry mouth, constipation, urinary retention, blurred vision, paradoxical effect

Bronchodilator Xanthine(caffeine) acts directly on .. muscle of bronchus and inhibits release of ... ^^^^^^^^smooth; SRS-A; (i.e. Theophylline by IV and Thoedor(sustained release); has narrow margin of safety of 10-20 ug/ml

Nursing considerations of bronchodilators... -^^^^^^^^initial therapy, stay with patient,quiet environment, upright position; percuss side and back to expel mucus plug then give aerosol; metered dose requires 2 puffs(wait 1min b/w puffs)

1. Rescue from acute Bronchoconstriction 2. Prevent recurrent episodes 3. Treat hyper-responsiveness caused by inflammation (prevent remodeling) -^^^^^^^^3 Approaches to Management of Asthma

B2 Agonist (albuterol, terbutaline, pirbuterol, bitolterol -^^^^^^^^Primary rescue agent; inhaled form most effective with least side effects -increase cAMP

Terbutaline, Epinephrine -^^^^^^^^Systemic B2 agonists -not as specific (hits B1, A1 and A2)

Ipratroprium and *Teotroprium (longer acting) -^^^^^^^^Muscarinic antagonist -not first line for rescue, use with inhaled B2 agonist

-use more in COPD

Corticosteroids -^^^^^^^^Used as systemic short course to establish control when starting bronchodilator therapy

Steroid anti-inflammatories -^^^^^^^^Primary agent to prevent recurrent episodes (daily prophylaxis)

Flunisolide, Fluticasone, Triamcinolone, Budesonide -^^^^^^^^Inhaled steroids

Prednisone, Methylprednisolone -^^^^^^^^Oral steroids (for severe, persistent asthma)

Inhibit PLA-2 > decreased AA>>decreased Leukotrienes and Prostaglandins -Basically decrease inflammatory mediators -^^^^^^^^MOA of steroids

Cromolyn and Nedocromil -^^^^^^^^Prevent de-granulation of Mast cells and Eosinophils -can use to treat periodic asthma (esp Cold-induced asthma)

1. Inhibit 5-lipoxygenase (can't make LT's) 2. Block LTD-4 receptors (LT's can't act on SM) -^^^^^^^^2 MOA's of Leukotriene modifiers

Zileuton -^^^^^^^^Inhibits 5-lipoxygenase

Zarfirlukast and Montelukast -^^^^^^^^Block LTD-4 receptors

AA (arachidonic acid) is a precursor for both Prostaglandins (via COX) andLT's(via lipoxygenase) --Block COX, more substrate for lipoxygenase and more leukotriene production. -^^^^^^^^10% of asthmatics are sensitive to Aspirin (bronchospasm). What's the mechanism? (remember Leukotrienes are very potent bronchioconstrictors)

Theophylline/Aminophylline -^^^^^^^^-Inhibits PDE (which breaks down cAMP) -block adenosine receptors on SM -Adjuvant to steroid for nocturnal symptoms

CNS stimulation and Narrow TI -^^^^^^^^Side effects of Theophylline

Salmeterol -^^^^^^^^Long-acting B2 agonist - must be used in combo with inhaled steroids

Histamine -^^^^^^^^primary mediator involved in upper airway allergies -locally acting hormone (autacoid) -found in Mast cells and Basophils

-decreased B.P (H1) -Increased HR (H2) -edema and increased cap. permeability -heat and redness -^^^^^^^^Cardiovascular effects of histamine

-pain and itching (H1) -inhibition of NT release (H3) -Cutaneous Triple Response -^^^^^^^^Nervous effects of histamine

-Bronchoconstriction (H1) -Watery secretions (nasal, H1) -^^^^^^^^Respiratory effect of histamine

-gastric acid secretion (H2) -^^^^^^^^GI effects of histamine

H1 receptors -^^^^^^^^located on SM of vessels and bronchi; endothelium and sensory nerve endings -especially prominent in nasal cavity -Gq coupled

H2 receptors -^^^^^^^^located primarily on gastric parietal cells -Gs coupled to cAMP elevation

H3 receptors -^^^^^^^^located on presynaptic nerves in brain -Gi coupled to N-type calcium channels

H4 -^^^^^^^^located on blood cells in BM and blood (eosinos and neutros)

-Gi coupled to cAMP and IC calcium decrease

1. Redness (local) 2. Edematous wheal (local endothelial contraction) 3. Red flare (axon reflex; at some separate lct) -^^^^^^^^Components of the Cutaneous Triple Response

Type I Allergic reaction (immediate) -activation of IgE -^^^^^^^^primary cause of histamine release

produce effect opposite to that produced by histamine -^^^^^^^^What is the goal of a physiological histamine antagonist?

Physiological antagonists to histamine -^^^^^^^^-Bronchodilators (B2 agonist) -Vasoconstrictors (alpha agonists) -degranulation inhibitors

Cromolyn and Nedocromil -^^^^^^^^degranulation inhibitors -used primarily for prophylactic tx of periodic allergies/asthma (example brought on by cold)

anti-histamines (1st or 2nd generation) -^^^^^^^^competitive H1 receptor blockers

1st Generation anti-histamines (Diphenhydramine, Dimenhydrinate) -^^^^^^^^-Block muscarinic receptors -cross BBB (may cause sedation due to anti-cholinergic) -short duration of action

2nd Generation anti-histamines (Loratidine, Fexofenadine) -^^^^^^^^-No muscarinic block -No cross BBB (no sedation) -longer duration of action

Not effective as Decongestant -^^^^^^^^While anti-histamines can do a lot of good for Allergic rhinitis and urticaria, what is their major shortfall?

Diphenhydramine -^^^^^^^^1st generation anti-histamine sometimes used for motion sickness and as a sleep aid

Vasoconstrictor -^^^^^^^^Many mediators apart from Histamine are involved in the production of congestion; what sort of drug do you need to treat it?

Phenylephrine, Pseudoephedrine, Oxymetazoline -^^^^^^^^common decongestants

Medulla Oblongata -^^^^^^^^where does the cough reflex originate?

Dextromethorphan, Codeine, Hydrocodone -^^^^^^^^Antitussives -at high dose can have PCP-like effect

Guaifenesin -^^^^^^^^Expectorant --careful when inhibiting expectorant cough; need to cough up mucus plugs

Acute -^^^^^^^^Short term, usually less than six months.

Alveoli -^^^^^^^^Tiny air sacs in the lungs that permit the exchange of oxygen and carbon dioxide through capillary walls.

Antihistamine -^^^^^^^^Drug that counteracts the effects of histamine, relieving allergy symptoms.

Antitussive -^^^^^^^^Drug that decreases coughing.

Apnea -^^^^^^^^Stoppage of breathing; may be temporary or fatal.

Bronchi -^^^^^^^^Air passages leading from the trachea to the bronchioles in the lungs.

Bronchiole -^^^^^^^^Branch of the bronchi leading to alveolar ducts.

Bronchodilator -^^^^^^^^Drug that increases the vital capacity of the lungs by dilating the bronchi and relaxing the smooth muscles.

Bronchopulmonary -^^^^^^^^Pertaining to the lungs and the air passages.

Chronic -^^^^^^^^Long term, usually more than six months.

Decongestant -^^^^^^^^Drug that reduces congestion or swelling, especially in nasal passages, by constricting blood vessels and restricting blood flow to the area.

Dyspnea -^^^^^^^^Labored or difficult breathing.

Emphysema -^^^^^^^^Condition in which the air sacs dilate and are unable to contract to their original size; the alveoli lose their elasticity, causing residual air to be trapped in them.

Epiglottis -^^^^^^^^Leaf-shaped structure on top of the larynx that seals off the air passages to the lungs during swallowing.

Expectorant -^^^^^^^^Drug that breaks down mucus to enable the patient to cough it up more easily.

Fowler's Position -^^^^^^^^Position in which the patient's upper body is raised 45 to 60 by means of pillows or by adjusting the head of the bed.

Hemoptysis -^^^^^^^^Spitting of blood.

Hyperpnea -^^^^^^^^Breathing too rapidly or deeply.

Hypoxia -^^^^^^^^Absence or decrease in oxygen.

Influenza -^^^^^^^^Flu

Inhaler -^^^^^^^^Handheld and pocketsize device used to administer a breathing treatment.

Larynx -^^^^^^^^Voice box; joins the pharynx with the trachea.

Mucolytic -^^^^^^^^Drug that liquefies or breaks down tenacious mucus so it can be coughed up more easily.

Nicotine Dependence -^^^^^^^^A physical vulnerability of the body to the chemical nicotine, which is brought on by tobacco products.

Orthopnea -^^^^^^^^Abnormal condition in which the patient must sit or stand to breathe deeply and comfortably.

Peak Flow Meter -^^^^^^^^A device that measures the air flowing out of the lungs, called the peak expiratory flow rate (PEFR), when a patient with asthma forcefully blows into the device.

Percussion -^^^^^^^^Physical therapy for respiratory patients; tapping of various body organs and structures.

Pharynx -^^^^^^^^Tube like structure that extends from the base of the skull to the esophagus; serves as both respiratory and digestive tracts.

Pleura -^^^^^^^^Membranes lining the lungs and lung cavities.

Pneumococcal Disease -^^^^^^^^Serious disease leading to infections of the lungs, the blood, and the meninges.

Postural Drainage -^^^^^^^^Physical therapy for respiratory patients; use of positioning along with vibration and percussion to drain secretions from specific areas of the lungs, bronchi, and trachea.

Productive cough -^^^^^^^^Cough that brings up large amounts of mucus.

Pulmonary -^^^^^^^^Pertaining to the lungs.

Pulse Oximeter -^^^^^^^^A device that monitors the oxygen saturation by placing a probe on the finger, toe, ear, forehead, or the bridge of the nose.

Rebound Effect -^^^^^^^^Reappearance of symptoms in even stronger form after a drug dose has worn off.

Respiration -^^^^^^^^Breathing.

Semi-Fowler's Position -^^^^^^^^Position in which the patient's upper body is elevated to 30.

Sputum -^^^^^^^^Abnormally thick fluid formed in the lower respiratory tract that may contain blood, pus, or bacteria.

Stethoscope -^^^^^^^^Instrument for listening to the heartbeat and breathing sounds.

Tachypnea -^^^^^^^^Rapid breathing.

Trachea -^^^^^^^^Windpipe; Connects larynx to bronchi.

Unproductive Cough -^^^^^^^^Cough that brings nothing up from the lungs; a dry cough.

Ventilator -^^^^^^^^Machine that assists breathing.

Vibration -^^^^^^^^Physical therapy for respiratory patients; a fine, shaking pressure applied to the chest wall during exhalation.

Viscosity -^^^^^^^^Thickness.

Coughing -^^^^^^^^Protective reflex to clear the trachea, bronchi, and lungs of secretions and irritants.

Wheezing -^^^^^^^^High-pitched, musical sound that occurs through a narrowed airway.

Pneumonia -^^^^^^^^Infection of the lower respiratory tract.

Sympathomimetic -^^^^^^^^mimics the sympathetic nervous system

Sympathetic Neuro-Receptors -^^^^^^^^Alpha: arteries and arterioles, B1: heart, B2: Lungs

Nor epinephrine -^^^^^^^^Sympathetic Nuero-transmitter

Adrenergic Bronchodilators -^^^^^^^^Drug class that directly stimulates Sympathetic Receptors

Effects of Epinephrine -^^^^^^^^Increased BP, Tachycardia, Skeletal Muscle Tremors, Short duration

Albuterol -^^^^^^^^Most common short acting bronchodilator

Levalbuterol -^^^^^^^^Single Isomer form of Albuterol (R Isomer)

Albuterol Dose -^^^^^^^^SVN: 2.5mg/3ml (unit dose), MDI 90 MCG/puff,

Levalbuterol Dose -^^^^^^^^SVN: 1.25mg/3ml (.31 &.63 mg/3ml) MDI: 45 MCG/puff

Long Acting Bronchodilators -^^^^^^^^For maintenance, duration 12hrs, Often used in combination w/ Corticosteroids

Long Acting Bronchodilator Rx <ADVair> -^^^^^^^^Salmeterol (Serevent) + Fluticasone (a synthetic corticosteroid.)= Advair

Advair -^^^^^^^^a bronchodilator and corticosteroid combination used to treat and prevent the symptoms of asthma.

Adrenergic AKA -^^^^^^^^Sympathomitmetic AKA

Muscarinic M2, M3 -^^^^^^^^Parasympathetic Receptors in the airways

Atropine -^^^^^^^^Non-selective Parasympathalitic Agent (a muscarinic receptor antagonist)

Anticholinergic agents -^^^^^^^^block acetylcholine receptors & act as cholinergic anatgonists

Cholinergic agents -^^^^^^^^uses acetylcholine as its neurotransmitter.

antiadrenergic -^^^^^^^^an antagonist of the Sympathetic Nervous System

Sympatholitic Agents -^^^^^^^^an agent blocking the effect of the Sympathetic Nervous System

Antiadrenergic AKA -^^^^^^^^Sympatholytic AKA

Sympathomimetic Agents -^^^^^^^^mimics the sympathetic system

Methylated Xanthines (CH3) -^^^^^^^^Caffeine, Theophylline and Theobromine

Clinical Indications for use of Xanthines -^^^^^^^^Considered the primary agent of choice for Apnea of Prematurity

Cholinesterase -^^^^^^^^The enzyme that degrades the parasympathetic neuro-transmitter

COMT/MAO -^^^^^^^^the enzymes that degrades the sympathetic neuro-transmitter

Synergism -^^^^^^^^two or more agents working on the same target organ, resulting in a product greater than the sum of its parts

Additivity -^^^^^^^^two agents working together resulting in a sum equal to both parts

Therapeutic Index -^^^^^^^^The appropriate dose that reduces risk of overdosing or underdosing

Riboviran -^^^^^^^^Drug used in extreme cases of RSV. Delivered via (SPAG) Small Particle Aerosol Generator

Albuterol inhalers -^^^^^^^^Ventolin, Proventil, Pro-Air (trade names)

Long -Acting Bronchodilators(12 hrs) -^^^^^^^^Serevent(Salmetrol) , Foradil(Formoterol), Brovana(Arformoterol)

Fluticasone + Salmeterol= -^^^^^^^^Advair Diskus (dpi) 50mcg /Seretide

Formoterol +Budesonide= -^^^^^^^^Symbicort

Albuterol + Ipratropium= -^^^^^^^^Combivent or DUOneb

Purpose of Mucus in physiology -^^^^^^^^effective lubricant, protective barrier, and sticky trap for foreign particles and microorganisms

Factors that slow mucus clearance -^^^^^^^^lung disease(COPD,CF), Airway drying, Narcotics, Airway Trauma, Cigarrette Smoking, Atmosphere pollutants

Mucolytics -^^^^^^^^agents that destroy or dissolve mucus, degrade mucin, helpful in opening airways

Mucomyst generic name -^^^^^^^^N. Acetylcysteine trade name

Pulmozyme generic name -^^^^^^^^the trade name or Dornase alfa-used with CF

N. Acetylcysteine -^^^^^^^^mucolytic,(mucomyst) may cause bronchospasm (use w/bronchdilator), limited shelf life (refrig)

Dornase Alfa -^^^^^^^^mucolytic,(Pulmozyme) disrupts DNA polymers, effective in CF

Bronchoalveolar Lavage (BAL) -^^^^^^^^bronchoscope passed through mouth or nose into the lungs, a fluid is squirted into a small part of the lung and then recollected for examination.

Chronotropic Drugs mode of action -^^^^^^^^Drugs that change the HR by affecting signals to the SA node

Ionotropic Drug's mode of action -^^^^^^^^Drugs that affect the myocardial contractility

Side effects to corticosteroid use -^^^^^^^^Osteoporosis, adrenal suppresion, mood changes

Three Classifications of Antiinflammatory Agents -^^^^^^^^Corticosteroids, Leukotriene Antagonists, and Mast Cell Stabilizers

Common ACE inhibitors -^^^^^^^^CaptroPRIL, LisinoPRIL, EnalaPRIL, BenzaPRIL

Angiotensins effect on Blood Pressure -^^^^^^^^Blood vessels constrict and raise blood pressures

Angiotensin Converting Enzyme Inhibitors Mode of Action(ACE Inhibitors) -^^^^^^^^Blocks the conversion of Angiotensin I to Angiotension II

bradykinin defined -^^^^^^^^substance released by damaged tissue that promotes inflammation

Antithrombotics defined -^^^^^^^^Prophylactic Drug to treat Formation of Clots (blood thinners)

Drugs used to treat Thrombosis -^^^^^^^^Coumadin, Heparin, Lovenox

Leukotrienes -^^^^^^^^Initiate and mediate the inflammatory response (singulair is a Leukotriene Antagonist)

Mast Cell Stabilizers -^^^^^^^^inhibit the release of inflammatory chemicals from mast cells and make the airways less likely to narrow.

Chronotropics which increase Heart Rate -^^^^^^^^Atropine and Isoproternol

Chronotropics which decrease Heart Rate -^^^^^^^^Adenosine and Metoprolol (Beta Blockers)

Combined Inhaled Medicines Defined -^^^^^^^^Bronchodilators that combine a controller inhaler and a quick relief inhaler, or combine 2 controller inhalers into one.

Pharmacodynamic Defined -^^^^^^^^The drugs affect on the Body

Pharmacokinetic Defined -^^^^^^^^The Body's affect on the Drug

Tachyphylaxis Defined -^^^^^^^^rapidly decreasing response to a drug following administration of initial doses

20% increase to heart rate over baseline -^^^^^^^^Considerations to stop treatment of SABA (Sign of Side Effect)

Adrenergic Antagonists -^^^^^^^^The most common Sympatholytic Agent (Drugs that inhibit the actions of the sympathetic nervous system by any mechanism)

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Normal ABG Values pH PaO2

7.35-7.45 80-100 35-45

PaCO2 O2 Sat HCO3 Base Excess

95-100 22-26 +_2

Hypoventilation Drug Overdose Pulmonary Edema

What are some causes of Respiratory acidosis?

Chest Trauma Neuromuscular Disease Airway Obstruction COPD

Diabetic Ketoacidosis Salicylate OD What are some causes of Metabolic Acidosis? Shock Sepsis Severe Diarrhea Renal Failure
Hyperventilation Initial Stage of Pulmonary Emboli Anxiety

What are some Causes of Respiratory Alkalosis?

Hypoxia Fever Pregnancy High Altitude Overuse of Antacids

What are some Causes of Metabolic

Alkalosis?

Loss of Gastric Juices (vomiting, NG tube) Potassium Wasting Diuretics (Increase loss of H+)

Hypoxia Signs of Hypoxia Emphysema Chronic Bronchitis Asthma COPD--Picture S&S

Inadequate amounts of oxygen available for Cellular Metabolism

Early: restless, tachycardia, tachypnea, dyspnea, increased agitation, diaphoresis, retractions, altered LOC Late: increased restlessness, somnolence, stupor, dyspnea, decreased respiration, bradycardia, cyanosis Kids: nares flaring, grunting, stridor, feeding problems

Destruction and Enlargment of Air Spaces; Loss of elasticity of alveoli

Inflammation and structural changes of airways. Rigidity of airway due to chronic inflammation and scarring.

airway narrowing due to hyper-responsiveness and bronchoconstriction

Easily Fatigued, Frequent Respiratory Infections, Use of Accessory Muscles, Orthopneic, Wheezing, Pursed Lip breathing, Chronic Cough, Barrel Chest, Dyspnea, Prolonged Expiratory Time, Digital Clubbing, Cor Pulmonale (late in disease), Thin in Appearance Hyperinflation and loss of elasticity of alveoli.

Emphysema Pathophysiology and Manifestation

Significant and progressive reduction in expiratory outflow Hyperinflation of lungs, bullae formation (can rupture and form a pneumothorax) Small airway collapse Dyspnea on exertion Chronic (minimum) cough and sputum productoin Barrel chest Speak in short jerky sentences Anxious Thin appearance Purse lip Breathing

What will the lungs of a patient with emphysema sound like? What will the skin color of a patient with

Hollow and Resonant. There will be hyperresonance on chest percussion. Pink because they do not retain CO2 well. They will have minimal cyanosis.

emphysema look like? Explain the complications of Emphsema Pts and Emphysema patients have exertional dyspnea. Exercise
Results from exposure of airways to irritants. As a result there will be scarring and rigidity of airway walls.

What is the Pathology of Chronic Bronchitis & its' manifestations

Thick, copious mucus production Chronic COUGH Hypoxemia and hypercapnea (respiratory aciosis)

Diagnosis of Chronic Bronchitis

1. Productive cough for 3 months in each of 2 consecutive years AND air flow obstruction 2. FEV==less than 70%

Pink PuFUHer/Blue Em FUH syma/Bronchitis BLOATER

Skin color: blue bloater, dusky to cyanotic Clubbing of fingers Breath sounds: crackles, rhonchi, wheezing Productive cough JVD (late sign=cor pulmonale)

What will be found on a physical exam of a pt with Chronic Bronchitis?

Hypoxia Hypercapnia Increased Respiratory Rate Cardiac Enlargment Use of Accessor Muscles to Breathe (Makes the right side of the heart work harder to pum blood into the lungs. REVERSIBLE airflow obstruction caused by inflammation and constriction of airway when exposed to irritant.

What is the Pathology of Bronchial Asthma and its Manifestations?

dyspnea

wheezing cough increased mucus production S/S mostly in early morning or night

Anxious Breath Sounds: Expiratory wheezing, tight Cough

Bronchial Asthma-Physical Findings

Asymptomatic between attacks Increase Mucus Production Shortness of Breath Prolonged Expiration Retractions

ASA and NSAIDs should be given with caution to patients Asthma with which respiratory condition?

Budesonide (Pulmoicort)--Class, Use

hydrocortisone (Solu-Cortef) What is it? methylprednisolone (Medrol, Solu-Medrol) What is it?

It is an anti-inflammatory and anti-allergy medication used to decrease or prevent the respiratory tissue response to the inflammatory process. It is used for maintenance prophylaxis and long term managment of asthma.

An anti-inflammatory/corticosteroid agent for IV. An anti-inflammatory/corticosteroid agent for IV or Oral. An anti-inflammatory/corticosteroid agent for Oral.
1. 2. 3. 4. fluticasone (Flovent HFA, Flovent Diskus) beclomethsone (Qvar) budesondie (Pulmicort Turbohaler) mometasone (Asmanex Twisthaler)

Prednison What is it?

Name four Antiinflammatory/Corticosteroid Inhalers

Name the Short acting and Long Acting Anticholinergic Drug

Short: ipatropium (Atrovent HFA) NEB or MDI Long: tiotropium (Spiriva Handihaler) DPI
albuterol (Proventil HFA, Ventolin HFA, ProAir HFA, AccuNeb, VoSpire ER [oral only)

Name the SABA

levalbuterol (Xopenex, Xopenex HFA) pirbuterol (Maxair Autohaler)

COPD, but not asthma. Should When can LABAs be used With be used with inhaled steroids when in monotherapy? treating asthma. salmeterol (Serevent) formoterol (Foradil Aerolizer, Perforomist) arformoterol (Brovana)
1. Exposure to foreign mattter 2. Inflammatory Response 3. Capillary Walls Become Leaky

Name the LABA

Pathophysiology of Pneumonia

4. Fluid shifts from capillaries to interstitial space and then to alveoli 5. Alveoli fill with fluid 6. Lungs lse compliance 7. VQ mismatch

1. Aspiration How does bad stuff get in the lungs to cause pneumonia? 2. Inhalation--mycoplasma and fungal 3. Hematogenous Spread-Staph aureus

What qualifies as a HCAP?

1. New Onset

2. person was hospitalized in a cute care hospital for 2 days or longer withing 90 days of the infection 3. Resided in LTCF 4. Received IV ABO therapy, chemotherapy, or wound care within past 30 days 5. Attended a hospital or hemodalysis clinic RALES, RHONCHI AND DIMINISHED BREATH SOUNDS, PRODUCTIVE COUGH, PURULENT OR RUST COLORED SPUTUM, FEVER CHILLS, DYSPNEA ON EXERTION, ELEVATED WBCS, DEHYDRATION, ABN CXR, ABN ABGS

PNEUMONA
Pleurisy Pleural Effusion Atelectasis Bacteremia Lung Abscess Empyema Pericarditis Meningitis Endocarditis

What are some complications of Pneumonia?

Assessment Findings: Progressive fatigue, Lethargy, Anorexia, Nausea, Weight Loss, Fever, Night Sweats, Productive Cough (white frothy, maybe bloody), Chest tightness, Dull Chest pain, Possible crackles, wheezing

Tuberculosis

For Tuberculosis Isoniazid (INH), Rifampin, Pyrazinamide, Ethambutol, Streptamycin treatment

What are the three mechanisms by whic the body regulates acid-base balance?
1. Buffer system--FAST 2. Lungs--excrete CO2 and water 3. Renal 1. secretion of small amounts of free hydrogen into the renal tubule 2. combination of H+ with NH3 to form ammonium (NH4+ 3. Excretion of weak acids

Respiratory Acidosis (carbonic acid excess) is Respiratory alkalosis

occurs when there is hypoventilation

Too much CO2=too much H+ occurs whenever there is hyperventilation

(carbonic acid deficit) Metabolic acidosis (base bicarbonate deficit) Metabolic alkalosis (base bicarbonate excess)

Too much oxygen, little CO2=little H+

occurs when an acid other than carbonic acid accumulates in the body or when bicarbonate is lost from body fluids

Pleural Effusion Pleural Effusion occurs secondary to:

Clinical Manifestations of a pleural effusion

occurs when a loss of acid (prolonged vomiting or gastric suction) or a gain in bicarbonate occurs abnormal accumulation of fluid in the pleural space (normal is 5 to 15 mL)

altered hydrostatic or oncotic pressure fluid collection bleeding into the space decreased lymphatic clearance of pleural fluid infection

dyspnea decreased movement on the affected side of chest wall pleuritic pain absent or distant breath sounds over affected side

inflammation of the pleura

Pleurisy & manifestations Atelectasis

pain is aggravated by inspiration shallow and rapid breathing o pleural friction rub (ausculatated)

lung condition characterized by collapse airless alveoli

an abnormal accumulation of fluid in the alveoli and interstitial spaces of the lung. A complication of various heart and lung disease. The most common cause is Left Sided Heart Failure.

Pulmonary Edema

Other Causes:

Overhydration from IV Hypoalbuminemia Altered capillar permeability of lungs Malignancies of lymph system o Respiratory distress syndrome

TOO, TOO much oxygen gets Gets rid of nitrogen causing alveolar rid of what causing what? collapse.

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1. Print This Note

Lower Respiratory Tract Drugs- Exam 2

Amy B Mon Feb 23 10:59:31 CST 2009

What is the prototype for mucolytic drugs?

Acetylcysteine (mucomyst)

Acetylcysteine (Mucomyst): Pharmacotherapeutics Pharmacodynamics

Pharmacotherapeutics * Liquefy thick, tenacious secretions Pharmacodynamics * Splits disulfide bonds that are responsible for holding the mucous material together.

What are other uses for Acetylcysteine (Mucomys) besides liquifying secretions?

*Acetaminophen antidote * Diagnostic studies

- Prevent contrast-induced renal complications of high risk patients - Diagnostic bronchoscopy

How do you maximize therapeutic effects with Acetylcysteine (Mucomyst)?

Administer inhaled beta agonist first to dilate bronchial tree Oral mix with diet soda

When is Acetylcysteine (Mucomyst) contraindicated?

Respiratory compromise and asthma Pregnancy/lactation

What are the adverse effects of Acetylecysteine (Mucomyst)?

Inhaled-bronchoconstriction, bronchospasm, chest tightness, burning in upper airway, rhinorrhea IV-anaphylactoid reaction

What is the usually the "rescue drug" with acute episodes with asthma?

Beta 2 agonists (vasodilates and relieves bronchospasm)

What is the prototype drug for Beta agonists that cause bronchodilation?

Albuterol (Proventil, Ventolin)

Albuterol (Proventil, Ventolin): Pharmacotherapeutics Pharmacodynamics

* BronchodilatorCAL and asthma

* Moderate selective-2 agonist.

It selectively stimulates receptors of smooth muscle in the lungs, the uterus, and the vasculature that supplies skeletal muscle. Relieves bronchospasm, reduces airway resistance facilitates mucous drainage, and increase vital capacity

What are the adverse effects of albuterol?

* More if orally taken Inhaled: Throat irritation, palpitations, anxiety and tremors Oral: Tachycardia, palpitations, anxiety, tremors, headache, insomnia, muscle cramps, and gastrointestinal (GI) symptoms

What can overuse of albuterol cause?

Rebound broncho-constriction

What is the important client teaching with albuterol?

Limit caffeine intake can increase the adverse effects Rescue drug first drug to use when symptoms of an acute attack occur. Teach how to use the MDI, DPI or nebulizer

What are the first-line drugs for CAL whose symptoms have become persistent?

Respiratory Anticholinergic Agents (such as Atrovent)

What is the prototype for Respiratory Anticholinergic Agents (that stops bronchoconstriction)?

ipratropium bromide (Atrovent)

ipratropium bromide (Atrovent): Pharmacotherapeutic Pharmacodynamics

Pharmacotherapeutics

Maintenance therapy for asthma or CAL

Pharmacodynamics Antagonizes the action of acetylcholine by blocking muscarinic cholinergic receptors Decrease contraction of smooth muscle Reducing bronchospasm

What are the adverse effects of ipratropium bromide (Atrovent)?

Most common: Cough, hoarseness, throat irriation, dysgeusia Rare-dry mouth, constipation, urinary retention, blurred vision (anticholinergic) Rare-paradoxical acute bronchospasm

What is the important client teaching w/ ipratropium bromide (Atrovent)?

Overuse may induce adverse effects. Atrovent is used prophylactically to reduce the frequency and severity of asthma attacks Must be taken daily despite the absence of symptoms It will not abort an asthma attack

What is the prototype for Xanthine Derivatives (bronchodilator)?

Theophylline (Slo-Phyllin)

Theophylline (Slo-Phyllin): Pharmacotherapeutics Pharmacodynamics

Pharmacotherapeutics Indicated for the symptomatic relief or prevention of bronchial asthma and reversal of bronchospasm associated with CAL.

Pharmacodynamics Believed that bronchodilation is caused by inhibition of phosphodiesterase.

What are the contraindications for Theophylline?

xanthines, status asthmaticus, & PUD, & pregnancy

What are the adverse effects of Theophylline?

>20 to 25 mcg/mL: GI-N,V, diarrhea CNS-headache, insomnia, irritability Serious: seizure and arrhythmias

What is the main drug interaction w/ Theophylline?

Smoking- decreases serum levels, and may need up to 50% increase in dose

What is the important client teaching with Theophylline?

Avoid large intake of caffeine foods and beverages Administer immediate-release with a meal to decrease GI distress Sustained-release on an empty stomach Smoking decrease serum levels Diet affects elimination of the drug

How does diet affect the elimination of Theophylline?

High carbs, low protein diets decrease elimination and high protein, low carb diets increase elimination

What are the main anti-inflammatory agents?

Glucocorticoids Mast cell stabilizers Leukotriene receptor antagonist

What is the prototype for Inhaled Glucocorticoid Steroids (ICS)?

Flunisolide (Aerobid)

Flunisolide (Aerobid): Pharmacotherapeutics Pharmacodynamics

Pharmacotherapeutics Used to prevent bronchospasm with asthma and CAL Maintenance drug not acute attacks Pharmacodynamics Inhibit production of leukotrienes and prostaglandins through interference with arachidonic acid metabolism. Reduce the migration/activity of the inflammatory cells Increase the number and enhance the responsiveness of beta receptors in airways Decrease mucous production.

When is Flunisolide (Aerobid) contraindicated?

with active systemic fungal infections

What are the adverse effects of Flunisolide (Aerobid)?

limited Sore throat, hoarseness, coughing, dry mouth, pharyngeal and laryngeal fungal infections. Daily ICSdysphonia and oropharyngeal Candida albicans

What is the important client teaching with Flunisolide (Aerobid)?

Rinse mouth after administration or ICS Signs of candidiasis (white patches) Smoking decreases effectiveness

Importance of daily use Use of beta-2 agonist before dilates the bronchial tree increases dispersion of the drug.

What pathological events leads up to an acute asthma attack?

Vasoactive substances, such as histamine, serotonin, bradykinin, and leukotrienes, are located within the mast cell. When the mast cell ruptures, these substances cause an inflammatory response, such as bronchial constriction

What is the prototype for mast cell stabilizers?

cromolyn sodium

cromolyn sodium: Pharmacotherapeutics Pharmacodynamics

Pharmacotherapeutics Prophylactic agents for mild to moderate asthma Acute bronchospasm induced by exercise

Pharmacodynamics Works at the surface of the mast cell to inhibit mast cell rupture and degranulation after contact with an antigen Prevents the release of histamine and SRS-A mediators

When is cromolyn sodium contraindicated?

With lactose intolerance

What are the adverse effects of cromolyn sodium?

Throat irritation, bronchospasm, cough Oral: lactose intolerance

What is important client teaching with cromolyn sodium?

Take daily; not a "rescue drug"

What are leukotrienes?

Leukotrienes are inflammatory mediators released from mast and t-cells. Leukotrienes are powerful bronchoconstrictors and vasodilators. Leukotrienes have been identified as important mediators in the pathology and symptomatology of asthma Result in airway hyperreactivity, bronchoconstriction, and hypersecretion

What is the prototype for Leukotriene Receptor Agonists?

Zafirlukast (Accolate)

Zafirlukast (Accolate): Pharmacotherapeutics Pharmacokinetics Pharmacodynamics

Pharmacotherapeutics Prophylaxis or treatment of chronic asthma Pharmacokinetics Oral/food decrease bioavailability 1 hour before or 2 hours after

Pharmacodynamics Blocks receptors for leukotrienes bound to amino acid cysteine (very potent vasoconstrictor)

What are contraindications for Zafirlukast (Accolate)?

Povidone, lactose, hepatic insufficiency, pregnancy, & NOT for kids

What are adverse effects of Zafirlukast (Accolate)?

h/a, gastritis, pharyngitis, rhinitis

What are main drug interactions w/ Zafirlukast (Accolate)?

Drugs metabolized through P-450 system, theophylline, warfarin, aspirin, erythromycin

How is Singulair (Montelukast) different from Zafirlukast (Accolate)?

Once a day dosing, approved for kids > 2yrs, doesn't inhibit cytochrome isoenzymes

Why has omalizumab (Xolair) gotten a lot of TV press? What is important to remember when administering? How does it work?

First monoclonal antibody directed against immunoglobulin E (IgE) and first biological therapy developed to treat asthma.

SQ. Wait 20 minutes to ensure powder dissolves.

Binds to mast cells and prevents mast cell rupture and degranulation.Binds to receptors on monocytes, eosinophils, epithelial cells and platelets to interfere with the release of inflammatory mediators and cytokines. In managing lower respiratory tract disorders, which main classes of drugs are used*Drugs can be grouped into mucolytic agents, such as acetylcysteine; bronchodilators, such as theophylline; and anti-inflammatory drugs, such as cromolyn sodium. Theophylline acts by stimulating two prostaglandins, which results in smooth-muscle relaxation in both the bronchi and vasculature. Beta-adrenergic agonists are sympathomimetic agents. That means the drugs mimic the action of norepinephrine. In the lungs, norepinephrine stimulates bronchodilation. Anticholinergic agents block the action of acetylcysteine. When acetylcysteine stimulates the lungs, bronchoconstriction occurs; thus, when its action is blocked, the bronchi do not constrict. In a patient with acute respiratory distress, which of the bronchodilators would be most effective? Beta-adrenergic agonists, such as albuterol, have the quickest onset of action. They are referred to as rescue drugs. Which of the antiinflammatory agents is the most effective? Glucocorticosteroids are the most powerful anti-inflammatory agents. What is the difference between glucocorticoid steroids given orally and by inhalation? Both drugs are effective in reducing inflammation. Glucocorticoid steroids given orally have the potential to cause more adverse effects because they are systemic. Steroids given by inhalation have a local action; thus, they cause fewer adverse effects. Cromolyn sodium works by stabilizing the mast cell. When the mast cell ruptures in response to an antigen, bronchoconstrictive substances such as histamine, bradykinin, serotonin, and leukotrienes are released. By

stabilizing the mast cell, the drug prevents release of these substances. Glucocorticoid steroids have a multitude of actions. In the lungs, they decrease the effectiveness of inflammatory cells, thus keeping the bronchioles open. Leukotriene antagonists block the ability of leukotrienes to bind to their receptor sites. Because leukotriene binding to these sites is what causes bronchoconstriction, bronchoconstriction is blocked. If a patient is taking inhaled steroids, an anticholinergic inhaler, and a beta-adrenergic agonist inhaler, which inhaler would you tell the patient to use first? The beta-adrenergic agonist inhaler should be used first because it has the fastest onset. It will open the bronchial tree, so that the other drugs can be dispersed farther into the lungs to exert their action.

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Your Results for "NCLEX-RN Review"

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Summary of Results for Litta Oglesby

Site Title: MyNursingKit for Pharmacology: Connections to Nursing Practice Book Title: Pharmacology: Connections to Nursing Practice Book Author: Adams Location on Unit X > Chapter 73 > Student Home > Site: NCLEX-RN Review Submitted: March 31, 2012 at 5:46 PM (UTC/GMT) 72% Correct of 10 questions
13 correct: 5 incorrect: 28% 72%

2 questions contain multiple pairs, scored for a total of 10 questions. More information about scoring

1.

A client with asthma asks which of the prescribed medications should be used in the event of an acute episode of bronchospasm. The nurse will instruct the client to use: Your Answer: Albuterol, a beta agonist bronchodilator, by inhalation. Rationale: There are two important items to consider: (1) the medication and (2) the route. A drug to abort bronchospasm should be given by inhalation in order to ensure rapid action directly at the site. An inhaled beta agonist such as albuterol meets both criteria. Option 2 is incorrect because although inhalants are delivered directly, they do not work quickly and are used for prevention of inflammation. Option 3 is incorrect because this anticholinergic is not approved as rescue therapy for treatment of acute bronchospasm. Option 4 is incorrect

because leukotriene modifiers are indicated for prevention of respiratory problems, not for treatment of acute bronchospasm. Furthermore, giving a medication PO would not be appropriate when treating acute bronchospasm. Cognitive Level: Analysis; Client Need: Safe, Effective Care Management; Nursing Process: Implementation

2.

A client is prescribed beclomethasone (Beclovent), a glucocorticoid inhaler. Education by the nurse will include: Your Answer: Rinse your mouth out well after each use. Rationale: Glucocorticoids can decrease the beneficial oral flora that will allow for an overgrowth of fungal infections such as candida. Rinsing the mouth removes any glucocorticoid drug deposited there, and prevents it from being being swallowed. Thus it decreases the likelihood of toxicity through systemic absorption. Option 1 is incorrect because it is the bronchodilators (e.g., adrenergic agonists, anticholinergics, and xanthines) that are likely to cause tachycardia, not glucocorticoids. Option 2 is incorrect because it is the xanthines (e.g., aminophylline and theophylline) that are chemically related to caffeine, not the glucocorticoids. It would not be restricted with a glucocorticoid. Option 4 is incorrect because it is the bronchodilators (e.g., adrenergic agonists, anticholinergics, and xanthines) that are likely to cause the client to feel shaky and nervous. Cognitive Level: Application; Client Need: Safe, Effective Care Management; Nursing Process: Implementation

3.

The nurse should inform the client who is prescribed a nebulizer treatment with a bronchodilator agent that a common adverse effect is: Your Answer: An increased heart rate with palpitations. Rationale: Bronchodilators (e.g., beta agonists, anticholinergics, xanthine derivatives) have an adverse effect on heart rate elevation and palpitations. Option 2 is incorrect because bronchodilators do not decrease the immune response the way certain anti-inflammatory agents do. Option 3 is incorrect because bronchodilator increase alertness. Option 4 is incorrect because bronchodilators relieve dyspnea. While some bronchodilators have been known to cause unexpected problems and paradoxical bronchospasm, this is uncommon and the question asks for a common adverse effect. Cognitive Level: Comprehension; Client Need: Safe, Effective Care Management; Nursing Process: Implementation

4.

The nurse should monitor the client who is taking corticosteroids for evidence of: Select all that apply. Your Answers: Infection. Hyperglycemia. Correct. Correct.

5.

A 4-year-old child with respiratory distress secondary to asthma has an order for a nebulizer treatment. The type of medication most likely to be given for asthma management is a: Your Answer: Beta agonist. Rationale: Beta agonists are agents that are used in the management of asthma that may be given to children younger than 5, and are available in formulations suitable for nebulizer treatments. The agents in options 2, 3, and 4 do not meet one or more of the criteria listed above. Cognitive Level: Analysis; Client Need: Health Promotion and Maintenance; Nursing Process: Planning

6.

Despite repeated demonstrations of proper inhaler use by the nurse, the client is unable to return a proper demonstration on the training inhaler. The client is becoming frustrated. The best action for the nurse to take is to: Your Answer: Provide a spacer for use with the inhaler. Rationale: Some clients have difficulty mastering the coordination between inhalation and activation of the medication. In these instances, a spacer will hold the medication cloud so that this is not a concern. The spacer has additional advantages because it results in a more effective delivery of the drug to the site of action and less drug deposition in the mouth and oropharynx. Additional practice may help in the long term, but it is not the priority for an immediate solution to the problem (option 1). The health care provider would not need to be contacted because the client has difficulty learning, provided that a solution is readily available (option 2). Substitution of an oral form of drug is not in the nursing scope of practice and, even if it were, an oral formulation would not be a suitable substitute because the onset of action would be delayed (option 4). Cognitive Level: Analysis; Client Need: Health Promotion and Maintenance; Nursing Process: Planning

7.

A 60-year-old man is prescribed ipratropium (Atrovent) for the treatment of asthma. The appropriate nursing intervention includes: Your Answer: Assessing for an enlarged liver. Correct Answer: Teaching the client to report the inability to urinate. Rationale: Ipratropium in an anticholinergic agent. Anticholinergics can cause urinary retention. Although urinary retention is uncommon with inhalant medications, clients should be aware of this potential side effect. Caffeine is not contraindicated for clients taking anticholinergic agents (option 1). Anticholinergic agents do not cause problems resulting in liver enlargement (option 2). These agents are more likely to cause constipation, not diarrhea (option 4). Cognitive Level: Application Client Need: Health Promotion and Maintenance Nursing Process: Implementation

8.

Match each prototype on the left to the category of drug it represents.

Option

Your Answer D. albuterol (Proventil, Ventolin, Volmax) C. ipratropium (Atrovent) B. beclomethasone (Beclovent, Beconase, Vancenase, Vanceril) A. zafirlukast (Accolate)

8.1 8.2 8.3 8.4

Beta-adrenergic agonists Anticholinergic corticosteroids Corticosteroids Leukotriene modifiers

9.

A client who is prescribed 400 mg/day of theophylline smokes two packs of cigarettes per day. The nurse knows that this will pose what complication? Your Answer: The dose may be inadequate to manage symptoms. Rationale: Smoking increases the clearance of the theophylline; therefore, a larger than usual dose may be required to maintain a therapeutic level of medication. Otherwise, the dosage is one that is adequate and safe. Smoking does not increase the stimulant effect (option 1). Smoking would not contribute to the likelihood of theophylline toxicity (option 3) or systemic side effects (option 4). Cognitive Level: Knowledge Client Need: Health Promotion and Maintenance Nursing Process: Planning

10.

Match each category of drug with its primary effect as a bronchodilator or anti-inflammatory agent. Option Your Answer A. Anti-Inflammatory Agent B. Bronchodilator D. Anti-inflammatory agent C. Bronchodilator E. Anti-inflammatory agent F. Bronchodilator Correct Answer A. Anti-Inflammatory Agent F. Bronchodilator E. Anti-inflammatory agent C. Bronchodilator D. Anti-inflammatory agent B. Bronchodilator

10.1 10.2 10.3 10.4 10.5 10.6

Corticosteroids Methylxanthines Mast cell stabilizers Anticholinergic corticosteroids Leukotriene modifiers Beta-adrenergic agonists

Rationale: Each category has a specific effect that plays a role in management of pulmonary disorders. Cognitive Level: Knowledge Client Need: Health Promotion and Maintenance Nursing Process: Implementation

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