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Acute bronchospasm causes severe respiratory distress and a wheezing sound from expiration of air
- symptoms are forceful expiration, dyspnea
- medical emergency - - REPORT IT IMMEDIATELY
C. NEBULIZERS
- droplets in the mist are much finer than those produced by inhalers
- can be done through a face mask or through a mouthpiece
- for certain patients, nebulizers may be superior to inhalers
- patients who have become unresponsive to a beta 2 agonist delivered with an inhaler may
respond when the same drug is administered with a nebulizer because the dose is administered
slowly (over several minutes) allowing bronchi to gradually dilate and the drug gains deeper and
deeper access to the lungs
- often used for children and “ill” adults
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Adverse Effects:
- unpleasant taste in the mouth can be managed with frequent sips of water, sucking on
sugarless candy, or chewing gum
- caution with dizziness - - patient may need help walking
- nausea can be managed with frequent small meals
Oral Agents = excessive doses will cause stimulation of cardiac beta 1 receptors to cause angina
pectoris and tachydysrhythmias
- patients should be instructed to report chest pain or changes in heart rate or rhythm
- tremor is caused by stimulation of beta 2 receptors in skeletal muscle
- with continued drug use, condition declines spontaneously
Adverse Effects:
Inhaled Agents = largely devoid of serious toxicity, even in high doses
= orophyaryngeal candidiasis and dysphonia (hoarseness, speaking difficulty)
- to minimize: gargle after each administration
employ a spacer during administration
= adrenal suppression may occur with long-term, high-dose therapy
- patients who have been switched from oral glucocorticoids to inhaled
glucocorticoids must be given supplemental oral or IV doses at times of stress
= bone loss – at least in premenopausal women
- to minimize: use the lowest dose possible
ensure adequate intake of calcium and vitamin D
participate in weight-bearing exercise
= slow growth in children / adolescents, but not decrease adult height (slows growth but
only temporarily)
- not sure if these agents suppress growth and development of the brain, lungs
and other organs
- prudent to reserve these drugs for older children and young children with
relatively severe asthma
= may increase risk of cataracts and glaucoma
Adverse Effects:
Oral Agents = prolonged therapy even in moderate doses can be hazardous
= adrenal suppression, osteoporosis, hyperglycemia, peptic ulcer disease, and
suppression of growth
= patients must be given increased doses of oral or IV glucocorticoids at times of stress
- failure to do so can prove fatal!
V. METHYLXANTHINES
- most prominent actions are: central nervous system (CNS) excitation, bronchodilation
cardiac stimulation, vasodilation, diuresis
A. THEOPHYLLINE
- benefits derive primarily from bronchodilation
- narrow therapeutic range
- usually administered by mouth
- not by inhalation because it is not active by this route
- although less effective than beta2 agonists, has a longer duration of action (when administered in a
sustained release formulation)
- because effects are prolonged, may be most appropriate for patients who experience
nocturnal attacks
- safe and effective therapy requires periodic measurement of blood levels
- do not change brands without the physician’s OK
1. Toxicity:
- uncommon at plasma levels below 20 mg/ml
- relatively mild reactions include nausea, vomiting, diarrhea, insomnia, restlessness
- serious adverse effects are most likely at levels above 20 mg/ml
- include severe dysrhythmias (v-fib) and convulsions that can be highly resistant to
treatment
- at first signs of toxicity, administration should cease
- if large amount of the drug has been ingested , ipecac can be given to induce vomiting,
followed by activated charcoal with a cathartic
- v-fib responds to lidocaine
- IV diazepam may help control seizures
2. Drug Interactions:
a. Caffeine – can intensify adverse effects on the CNS and heart
- can compete with theophylline for drug-metabolizing enzymes, causing levels to rise
- should avoid caffeine-containing beverages, chocolates, and grilled foods
b. Drugs that Reduce Theophylline Levels – phenobarbital, phenytoin, rifampin
- lower theophylline levels by inducing hepatic drug-metabolizing enzymes
- concurrent use with these agents may require an increase in theophylline dosage
MANAGEMENT OF ASTHMA
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2. Peak Expiratory Flow Rate (PEFR) – maximal rate of airflow during expiration
- patient exhales as forcefully as possible into a peak flow meter (relatively inexpensive,
handheld device)
- patients should measure their peak flow every morning
- if peak flow is less than 80% of their personal best, more frequent monitoring should
be done
B. DRUG THERAPY
- some agents are taken to establish long-term control
- administered daily to achieve and maintain control of persistent asthma
- anti-inflammatory drugs – especially inhaled glucocorticoids – provide the foundation for long-
term control
- long-acting inhaled beta 2 agonists are also important
2. Mild Persistent – requires a combination of long-term control medication plus quick-relief medication
- foundation of treatment is daily inhalation of an anti-inflammatory drug
3. Moderate Persistent – requires intensive long-term control achieved by either inhaling a glucocorticoid
in a medium dose (compared to low dose in #1) OR inhaling a glucocorticoid in a low dose and
adding a long-acting inhaled beta 2 agonist (generally preferred method)
4. Severe Persistent – severe chronic asthma managed with daily inhalation of a high dose glucocorticoid
plus a long-acting beta2 agonist
- if symptoms are especially severe, an oral glucocorticoid should be added to regimen
- administration may be once daily or once every other day
- breakthrough attacks are managed with a short-acting, inhaled beta 2 agonist
- triggers include tobacco smoke, wood smoke, strong odors, weather changes, viral or sinus infections,
exercise, reflux disease, medications or food, emotional anxiety and household sprays
Risk Reducers: weekly washing of family pets that must stay in the home
encasing the patient’s pillow, mattress and box spring with covers that are impermeable
to allergens
washing all bedding and stuffed animals weekly on the hot cycle
removing carpeting or rugs form the bedroom
don’t smoke or be around smoke
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