PHARMACOLOGY Diffusion • Refers to the movement of

molecules from higher to lower

1F: NURSING CARE OF CLIENTS WITH concentration
DRUGS AFFECTING THE RESPIRATORY • Takes place when oxygen passes
into the capillary bed to be
SYSTEM
circulated
➢ Respiratory System • Carbon dioxide leaves the
• Respiratory tract is divided into two major parts: capillary bed and diffuses into the
alveoli for ventilatory excretion.
Two Major Parts of the Respiratory System ** Efficient and effective respiration and gas
Upper Respiratory Lower Respiratory exchange happen when the respiratory tract is free
Tract Tract from obstructions.
• Nares • Trachea
• Nasal cavity • Bronchi Upper Respiratory Disorders
• Pharynx • Bronchioles • Includes common cold, acute rhinitis, sinusitis,
• Larynx • Alveoli acute pharyngitis
• Alveolar capillary ➢ Common Cold
membrane • The most prevalent type of upper respiratory
** Air enters through the upper respiratory tract and infection
travels through the lower respiratory tract where gas • Adults have an average of 2-4 colds per year
exchange occurs. • Children have an average of 4 – 12 colds per
year
• Not considered a life-threatening illness, but it
does cause physical and mental discomfort, loss
Ventilation vs Respiration time at work and school
Both are distinct terms and should not be used • Caused by rhinovirus
interchangeably. • Affects primarily the nasopharyngeal tract
• Ventilation • Respiration • Most contagious 1-4 days before the onset of
Movement of air from the The process whereby symptoms
atmosphere from the gas exchange occurs at • Symptoms:
upper and lower airways the alveolar-capillary o Rhinorrhea
to the alveoli membrane. o Nasal congestion
o Cough
o Increased mucosal secretion
3 Phases of Respiration
• Drugs:
Ventilation • Phase in which oxygen passes o Antihistamine
through the airways. With every
o Decongestants
inspiration, air moves into the
o Antitussives
lungs. With every expiration, air is
o expectorants
transported out of the lungs.
➢ Acute Rhinitis
Perfusion • Happens after ventilation
• Acute inflammation of the mucous membrane of
• Involves blood flow at the alveolar the nose
capillary bed
• Usually accompanies common cold
• The influence by alveolar
• Nasal secretions increase
pressure
➢ Allergic Rhinitis
• For gas exchange to occur, the
• Hay fever
perfusion of each alveolus must
• Not the same as acute rhinitis
be matched by adequate
ventilation. • Caused by pollen or a foreign substance such as
animal dander
• Factors such as mucosal edema,
secretions, and bronchus spasm, • Nasal secretions increase
increases resistance to air flow
and decrease ventilation and
diffusion of gases.

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 ANTIHISTAMINES • It blocks the effects of histamine by competing
One of the medications used for upper respiratory for and occupying H1 receptor sites
tract disorders. • It has an anticholinergic effect and should not be
• AKA H1 blockers of H1 antagonists used to patients with narrow-angle glaucoma
• Competes with histamine for receptor sites • Drowsiness is a major side effect of this drug
and prevent histamine response • Also used as an antitussive (can be used to
• Act by blocking the H1 receptors suppress cough)
• Decreases nasopharyngeal secretions by • Onset of Action:
blocking the H1 receptor o 15 minutes (PO and IM)
** When these two receptors are stimulated, they o Immediate (IV)
produce different responses. • Can cause central nervous system (CNS)
• H1 – when stimulated, extravascular smooth depression if taken with alcohol, narcotics,
muscles (including those lining the nasal hypnotics, or barbiturates
cavity) constrict Nursing Interventions:
• H2 - when stimulated, gastric secretion occurs • Give the oral form of drug with food to decrease
• Indications: gastric distress.
o Cold • Administer the IM form in a large muscle
o Allergic rhinitis • Warn patient to avoid driving a motor vehicle and
o Urticaria performing other dangerous activities if
• Not used for anaphylaxis drowsiness occurs or until stabilized on the drug.
** Most antihistamines are rapidly absorbed in 15 • Advise patients to avoid alcohol and other CNS
minutes, but they are not potent enough to combat depressants
anaphylaxis. • Teach patients on prophylaxis for motion
sickness to take the drug at least 30 minutes
before the offending event and before meals and
1st Generation Antihistamines at bedtime.
• Mostly can cause drowsiness, dry mouth,
decreased secretion and other anticholinergic 2nd Generation Antihistamines
symptoms
• Have fewer anticholinergic effects and a lower
• Contained in many OTC cold remedies
incidence of drowsiness
Drug Examples:
• Frequently called nonsedating
• Brompheniramine tannate antihistamines
• Chlorpheniramine • Cause fewer anticholinergic symptoms
• Clemastine fumarate Drug Examples:
• Diphenhydramine • Azelastine
• Cyproheptadine • Cetirizine
• Levocetirizine • Fexofenadine
• Azelastine and fluticasone • Loratadine
Side Effects: (most common) • Desloratadine
• Drowsiness ** The same with the first generation
• Dizziness anithistamines, these medications are also usually
• Fatigue given to patients with allergic rhinitis, pruritus, and
• Disturbed coordination urticaria
Other Side Effects:
• Skin rashes
• Anticholinergic symptoms NASAL AND SYSTEMIC
DECONGESTANTS
Nasal congestion – results from the dilation of
➢ Diphenhydramine the nasal blood vessels caused by infection,
• Primarily used to treat rhinitis inflammation, or allergy.
• Also used for common cold, cough, sneezing, ** With this dilation, a transudation of fluid into the
pruritus, urticaria, and to prevent motion tissue spaces occurs. That leads to the swelling of
sickness the nasal cavity.
• Can be administered orally, IM or IV
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 • Nasal decongestant – medications used to o Decongestants + MAOIs → increased
treat nasal congestion possibility of hypertension or
o Sympathomimetic amines in nature cardiac dysrhythmia
o Stimulate the alpha-adrenergic o Decongestants + caffeine →
receptors, which leads to: increased restlessness and
o Vascular constriction of the capillaries palpitations
within the nasal mucosa
o Shrinking of nasal mucous membrane
and fluid secretion reduction INTRANASAL GLUCOCORTICOID
➢ Nasal Decongestants • Effective for treating allergic rhinitis
• Administered by nasal spray of drops, or in • With anti-inflammatory action → decrease the
tablet, capsule or in liquid form allergic rhinitis symptoms of rhinorrhea,
• Frequent use (esp. nasal spray or drops) sneezing, and congestion
→ tolerance and rebound nasal congestion • Drug Examples:
• Act promptly and cause fewer side effects than o Beclomethasone
systemic decongestants o Budesonide
• Not to use more than 1 or 2 puffs 2-6x a day o Flunisolide
for 5-7 days because of rebound congestion o Fluticasone
➢ Systemic Decongestants o Mometasone
• Available in tablet, capsule and liquid form o Triamcinolone
• Used primarily for allergic rhinitis including hay • Spray should be directed away from the nasal
fever and acute coryza septum and patient should sniff gently
• Relieves nasal congestion for a long period • Continuous use → dryness of the nasal
than nasal decongestants mucosa may occur
• Drug Examples: • Side Effects:
o Tetrahydrozoline o Headache
o Oxymetazoline HCl o Nasal irritation
o Pseudoephedrine o Pharyngitis
o Phenylephrine HCl o Fatigue
** The incidence of side effects is low with topical o Insomnia
preparations such as nose drops. Side Effects o candidiasis
however disappear as the body adjusts to the
drug.
ANTITUSSIVES
• Side Effects:
o Nervous • act on the cough control center in the medulla
o Restless to suppress the cough reflex
o Rebound nasal congestion (nasal • the cough is a natural protective way to clear
decongestants; used for as little as 3 days) the airway of secretions or any collected
** Instead of the nasal membranes constricting, material
vasodilation occurs causing increased stuffy nose • for nonproductive and irritating cough
and nasal congestion. Types:
** The nurse should emphasize the importance of 1. nonopioid
limiting the use of nasal sprays and drops. o Benzonatate
** As with alpha adrenergic drug, such as systemic 2. opioid
decongestants, o Codeine
o BP increases o Dextromethorphan
o Blood glucose increases o Guaifenesin
• Contraindication/Extreme caution: o Homatropine 1.5 mg and
o Hypertension Hydrocodone 5 mg
o Cardiac disease 3. combination preparations (with
o Hyperthyroidism expectorant)
o Diabetes Mellitus o Guaifenesin
o Dextromethorphan
• Drug Interactions:
o Pseudoephedrine + beta blockers →
may decrease beta blocker effect
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 • Can be caused by a virus, beta-hemolytic
streptococci or other bacteria
➢ Dextromethorphan • Can occur alone or with common cold and
• Available in syrup or liquid, chewable capsules rhinitis or acute sinusitis
and lozenges • Symptoms:
• Provides temporary cough relief especially due o Elevated temperature
to a non-productive cough o cough
• Acts by decreasing the excitability of the cough • Throat culture first (should be obtained to rule
center in the medulla out beta-hemolytic streptococcal infection)
• Preparations with dextromethorphan can be ** If the culture is positive for beta-hemolytic
used several times a day streptococci, a 10-day antibiotic therapy
• Side Effects: (bacterial)
o Dizziness • Saline gargles, lozenges and increased fluid
o Drowsiness intake are usually indicated.
o Confusion ** Acetaminophen may be taken to decrease
o Fatigue elevated temperature.
o Ataxia ** Antibiotics are not effective for viral pharyngitis.
o Nausea
o Vomiting
o restlessness Respiration

• Oxygen, carbon dioxide, and hydrogen ion

EXPECTORANTS concentrations in the blood influence respiration
• loosen bronchial secretions so they can be • Chemoreceptors are sensors that are stimulated
eliminated by coughing by changes in these gases and ions.
• used for productive cough (antitussives = • Chemoreceptors are located centrally and
nonproductive cough) peripherally.
• can be used with or without other • The central chemoreceptors, which are located
nonpharmacologic agents in the medulla near the respiratory center and the
• Guaifenesin – most common expectorant cerebrospinal fluid, respond to an increase in
• Hydration is the best natural expectorant carbon dioxide and a decrease in pH by
• Patient must increase fluid intake while taking increasing ventilation.
expectorant
• However, if the carbon dioxide level remains
• Side Effects:
elevated, the stimulus to increase ventilation is
o Drowsiness
o Dizziness lost.
o Headache • Peripheral chemoreceptors are in the carotid and
o Nausea aortic bodies. It responds to changes in oxygen
o Vomiting levels.
o diarrhea • A low blood oxygen level stimulates the
peripheral chemoreceptors which in turn
stimulate the respiratory center in the medulla,
Sinusitis and ventilation is increased.
• Inflammation of the mucous membrane of one
• If oxygen therapy increases the oxygen level in
or more of the maxillary, frontal, ethmoid or
the blood, the oxygen may be too high to
sphenoid sinuses
• Systemic or nasal decongestants may be stimulate the peripheral chemoreceptors, and
indicated the ventilation will be depressed.
• Acetaminophen, fluids and rest may be helpful • Take Note: the tracheo-bronchial tube consists
• Antibiotic may be prescribed for acute or of smooth muscles whose fibers spiral around
severe sinusitis the trachea-bronchial tube.
• Contraction of these muscles constrict the
airway.
Acute Pharyngitis
• Inflammation of the throat or sore throat
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• The sympathetic and the parasympathetic • Wheezing, mucous secretions and dyspnea
nervous system affects the bronchial smooth ** Bronchospasm results when the lung tissue is
muscles in opposite ways. exposed to extrinsic or intrinsic factors that
• The vagus nerve releases acetylcholine, which stimulate the broncho constrictive response
causes Bronchoconstriction • Triggers:
• The sympathetic nervous system releases o Stress, allergies (animal dander, dust
epinephrine which stimulates beta 2 receptors in mite, food drugs), pollutants,
the bronchial smooth muscle, resulting in humidity, air pressure changes,
Bronchodilation. temperature changes, smoke,
• These two nervous systems counterbalance fumes, emotional upset, and
each other to maintain homeostasis. exercise
Cyclic Adenosine Monophosphate (cAMP)

• Increase bronchodilation by relaxing the

bronchial smooth muscles.
• Phosphodiesterase enzyme can inactivate
cAMP

Lower Respiratory Tract Disorders

➢ Chronic Obstructive Pulmonary Disease
• Caused by airway obstruction with increased
airway resistance of airflow to lung tissues.
o Chronic bronchitis ** How Bronchial Asthma develops **
o Bronchiectasis ➢ Chronic Bronchitis
o Emphysema • Progressive lung disease
o Asthma • Caused by smoking or chronic lung
** Frequently result in irreversible lung tissue infections
damage.
• Bronchial inflammation and excessive
** The lung tissue changes that result from an acute
asthmatic attack are normally reversible. However, mucous secretion → airway obstruction
if the attacks are frequent and asthma becomes • Productive coughing (due to the presence of
chronic, irreversible changes in the lung tissue may excessive mucous secretion; in attempt to
result remove the excessive mucus)
➢ Restrictive Pulmonary Disease • Inspiratory and expiratory rhonchi may be
• Refers to the decrease in total lung capacity as heard
a result of fluid accumulation or the loss of ** Because of this problem, there is poor gas
elasticity of the lungs. exchange in the lungs.
• May be due to: • Hypercapnia and hypoxemia → respiratory
o Pulmonary edema acidosis
o Pulmonary fibrosis
o Pneumonitis
➢ Bronchiectasis
o Lung tumors • Abnormal dilation of the bronchi and
o Thoracic deformities (scoliosis) bronchioles due to frequent infection and
o Disorders affecting thoracic muscular inflammation
wall ** just like in bronchial asthma and chronic
bronchitis, where there is obstruction, the same
happens to bronchiectasis. But this time, the
Chronic Obstructive Pulmonary cause of obstruction is the breakdown of the
Disease epithelium
➢ Bronchial Asthma
• Characterized by periods of bronchospasm
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 • Bronchioles become obstructed by the ** When alpha1 receptors In the blood vessels are
breakdown of the epithelium of the bronchial activated, it leads to vasoconstriction and later on
mucosa and tissue fibrosis may result will lead to increased blood pressure.
** When beta1 receptors in the heart are activated,
➢ Emphysema
this will lead to increased heart contraction and
• Progressive lung disease caused by increased heart rate, which then also later on
smoking, atmospheric contaminants, or lack leads to increased blood pressure.
of the alpha-antitrypsin protein that inhibits ** when beta2 receptors in the lungs are activated,
proteolytic enzymes that destroy alveoli (air it leads to bronchodilation.
sacs) ** That Is why epinephrine are used for
• Terminal bronchioles become plugged with anaphylaxis reactions
mucous, causing a loss in the fiber and ** Manifestations of anaphylactic reactions could
elastin network in the alveoli include:
• Alveoli enlarge as many of the alveolar walls • Hypotension
are destroyed • Narrowing of airways
• Air is trapped in the overexpanded alveoli,
leading to inadequate gas exchange SYMPATHOMIMETICS: Albuterol
Patient Problems: • Beta2 adrenergic agonist
• Airway obstruction • Stimulates beta2-adrenergic receptor in the
• Dyspnea lungs which relaxes the bronchial smooth
• Decreased gas exchange muscle → bronchodilation
• Fatigue • Indication: asthma and bronchospasm
Medications: • High dose or overuse may cause some degree
of beta1 response → nervousness, tremor
• Bronchodilators (sympathomimetics, and increase pulse rate
parasympatholytic, and methylxanthines to • Nursing Intervention: monitor heart rate of the
assist in opening the narrowed airways) patient when albuterol is administered in high
• Glucocorticoids (used to decrease doses
inflammation)
• Leukotriene modifiers (used to reduce
inflammation in the lung tissue) SYMPATHOMIMETICS: Metaproterenol
• Expectorants (assist in loosening the mucus • Has some beta1 effect but is primarily used as
from the airways) beta2 agents
• Can be administered orally or by inhalation
• Antibiotics (to prevent serious complications
with a metered-dose inhaler or nebulizer
from bacterial infections) • Onset of action is 1 minute by oral inhalation,
5-30 minutes by nebulization, and 15-30
** Sympathomimetics or Alpha and Beta 2 minutes when taken orally
Adrenergic Agonists as medications used to manage
COPD. SYMPATHOMIMETICS:
** Are used for COPD as bronchodilators. This Other Drug Examples
medication will assist in the opening of the narrowed Alpha- and Beta- Beta- Adrenergics
airways Adrenergics
• Ephedrine sulfate • Albuterol
SYMPATHOMIMETICS: Epinephrine • Epinephrine • Formoterol
• Acts on alpha1, beta1, beta2 adrenergic • Revefenacin • Levalbuterol
receptor sites • Metaproterenol
• Promotes bronchodilation and elevates blood sulfate
pressure • Salmeterol
• Used during anaphylaxis reaction through • Terbutaline sulfate
subcutaneous route • Arformoterol
tartrate
• Indacaterol
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 • Olodaterol o Used to treat COPD
Side Effects and Adverse Reactions: o More effective and has longer duration of
• Epinephrine: tremors, dizziness, action
hypertension, tachycardia, palpitation, o Increases the forced expiratory volume in
dysrhythmia, and angina 1 sec (FEV1)
• Beta2-adrenergics: tremors, headaches,
restlessness, increased PR and palpitations
(high doses); increased blood glucose METHYLXANTHINE (XANTHINE)
DERIVATIVES
• Aminophylline
ANTICHOLINERGICS • Theophylline
** Anticholinergics or Parasympatholytics are used as • Caffeine
bronchodilators. ➢ Aminophylline-Theophylline
• Drug Examples: • Relaxes the smooth muscle of the bronchi,
o Ipratropium bromide bronchioles, and pulmonary blood vessels by
o Aclidinium inhibiting the enzyme phosphodiesterase →
o Tiotropium increase in cAMP → bronchodilation
o Umeclidinium ➢ Theophylline
➢ Tiotropium • Has a low therapeutic index and a low desired
• Used for maintenance treatment of therapeutic range: 5-15 mcg/mL
bronchospasm associated with COPD • Toxicity is likely to occur if serum level is beyond
• Acts mainly on the muscarinic receptors located in 20 mcg/mL
the airways to produce smooth muscle relaxation • For maintenance therapy in patients with chronic
and bronchodilation stable asthma and other COPDs
• Administered by inhalation only with HandiHaler • Contraindications:
device. o Seizure disorder
o Cardiac, renal or liver disease
• Patient must avoid smoking (smoking increases
drug elimination which may require increased
drug dosage)
• Advise patients that a high-protein, low-
carbohydrate diet increases theophylline
elimination. Conversely, a low-protein, high-
carbohydrate diet prolongs half-life.
• Side Effects and Adverse Reactions:
o Anorexia
o Nausea
• Adverse Effects:
o Vomiting
o Dry mouth
o diarrhea
o Constipation
o gastric pain
o Vomiting
o hematemesis
o Dyspepsia
o dysrhythmia
o Abdominal pain
o tachycardia
o Depression
o palpitation
o Insomnia
o hypotension
o Headache
o CNS: headache, irritability, restlessness,
o Joint pain
insomnia, dizziness, seizure – more severe
o Peripheral edema
in children
o Chest pain
o Can cause hyperglycemia
➢ Ipratropium
o Decreased clotting time and leukocytosis
• Used to treat asthmatic conditions by dilating the o Rapid IV administration: dizziness,
bronchioles
flushing, hypotension, severe bradycardia,
• Has few systemic effects and palpitation
• Administered by MDI (metered dose inhaler)
• Ipratropium + Albuterol:
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 LEUKOTRIENE RECEPTOR ANTAGONISTS
AND SYNTHESIS INHIBITORS
➢ Cysteinyl Leukotrienes
• promotes an increase in eosinophil migration,
mucous production, and airway wall edema →
bronchoconstriction
• AKA Leukotriene modifiers
• Effective in reducing the inflammatory symptoms
of asthma triggered by allergic and environmental
stimuli
• Not recommended for acute asthma attack
• Only for prophylactic and maintenance drug
therapy for chronic asthma
• Examples:
o Zafirlukast
o Zileuton
o Montelukast
➢ Zafirlukast
• 1st drug in the class of leukotriene modifier
• Leukotriene receptor antagonist
• For asthma
• Reduce inflammatory process and decreased
bronchoconstriction
• Route: PO
• Given 2x a day
• To take in the evening for maximum effectiveness
➢ Zileuton
• Leukotriene synthesis inhibitor
• For asthma
• Decreases the inflammatory process and
decreases bronchoconstriction
➢ Montelukast
• Leukotriene receptor antagonist
• For allergic rhinitis and asthma
• Considered safe for children 2 years of age and
older
• To take in the evening for maximum effectiveness
GLUCOCORTICOIDS (STEROIDS)
• Used for COPD because it can decrease
inflammation
• For asthma
• Have an anti-inflammatory action and are
indicated if asthma is unresponsive to
bronchodilator therapy
• Or if patient has an asthma attack while on
maximum dose of theophylline or an adrenergic
drug
Method of Administration:
• MDI Inhaler: Beclomethasone
• Tablet: Dexamethasone, Prednisone
• Intravenous: Dexamethasone
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• Inhaled glucocorticoids are not helpful in treating
severe asthmatic attack because it may take 1-4
weeks for an inhaled steroid to reach its full effect.
• When maintained on inhaled glucocorticoids,
asthmatic patients demonstrate an improvement
in symptoms and a decrease in asthmatic attack
• More effective for controlling symptoms of asthma
than beta2 agonists, particularly in the reduction
of bronchial hyperresponsiveness
• The use of oral inhaler minimizes the risk of
adrenal suppression associated with oral
systemic glucocorticoid therapy
** Inhaled glucocorticoids are preferred over oral
preparations unless they fail to control the asthma.
** The National Asthma Education and Prevention
Program Guidelines recommend systemic
glucocorticoids Prednisone, Prednisolone,
Dexamethasone, Methylprednisolone for
management of moderate to asthma exacerbations.
• Oral or IV administration of methylprednisolone
40-80 mg/day in 1-2 divided doses may be given
for 3-10 days.
• Single dose or short-term use glucocorticoids may
be discontinued abruptly after symptoms are
controlled.
• Suppression of adrenal function usually does not
occur within 1-2 weeks
• Prolonged glucocorticoid therapy for severe
asthma requires weaning or tapering of the dose
to prevent exacerbation of asthma symptoms and
suppression of adrenal function
• Glucocorticoids can irritate the gastric mucosa
• Should be taken with food to avoid ulceration
• Side Effects for orally inhaled: (generally local)
o Throat irritation
o Hoarseness
o Dry mouth
o Coughing
• Oral, laryngeal, and pharyngeal fungal infections
have occurred but can be reversed
• Candida albicans oropharyngeal infections may
be prevented by using a spacer, rinsing the mouth
and throat with water after each dose and washing
the apparatus daily with warm water.
** to reduce drug deposits in the oral cavity.
• Oral and injectable glucocorticoids SE:
o Headache
o Euphoria
o Confusion
o Diaphoresis
o Hyperglycemia
o Insomnia
o Nausea
o Vomiting
o Weakness
 o Menstrual irregularities
• Oral and injectable glucocorticoids AE:
o Depression
o Peptic ulcer
o Loss of bone density
o Development of osteoporosis
o Psychosis
• Oral and IV steroids SE/AR:
o Electrolyte imbalance
o Fluid retention
o Hypertension
o Thinning of the jhair
o Purpura
o abnormal subcutaneous fat
distribution
o Hyperglycemia
o impaired immune response

CROMOLYN
• Acts as an anti-inflammatory agent by
suppressing the release of histamine and other
mediators from the mast cells to prevent an
asthma attack
• For prophylactic treatment of bronchial asthma
• Must be taken daily
• Not for acute asthmatic attacks (because it does
not have a bronchodilator property)
• Postnasal drip, irritation of the nose and throat,
and cough – most common Side Effect
• Can be decreased by drinking water before and
after using the drug
• Method of Administration: oral inhalation via
MDI or nebulizer, and nasal inhalation via metered
spray
** Can be used with beta adrenergics and xanthine
derivatives
• Rebound bronchospasm – serious side effect of
Cromolyn; drug should not be discontinued
abruptly because a rebound asthmatic attack can
result

ANTIBACTERIALS
• Used only if a bacterial infection results from
retained mucous secretions
• Trimethoprim-sulfamethoxazole is effective for
the treatment of mild to moderate acute
exacerbations of chronic bronchitis from infectious
causes

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