UPPER RESPIRATORY DISORDERS

Compare antihistamine, decongestant antitussive and expectorant drugs

Differentiate between rhinitis, sinusitis and pharyngitis

Describe SE of nasal decongestants and how they can be avoided

Apply the nursing process for drugs used to treat common cold

2 divisions or respiratory tract: upper- nares, nasal cavity pharynx and larynx

Lower – trachea, bronchi, bronchioles, alveoli and alveolar-capillary

membrane. Where gas exchanges occur.

Ventilation is the movement of air from atmosphere through upper and lower airways to alveoli. Every
inspiration, air is moved to lungs and with every expiration, air is transported out of lungs.

Perfusion involves blood flow at the alveolar-capillary bed, it is influenced by alveolar pressure. For gas
exchange to occur, the perfusion of each alveolus must be matched by adequate ventilation.

Factors such as mucosal edema, secretions and bronchospasm increase resistance to air flow and
decrease ventilation and gas diffusion.

Diffusion, is the movement of molecules from higher to lower concentration takes place when oxygen
passes into the capillary bed to be circulated and carbon dioxide leaves the capillary bed and diffuses
into the alveoli for ventilatory excretion

Upper respiratory infections URIs include common cold, acute rhinitis, sinusitis and acute pharyngitis.
Cold is the most prevalent. Cold is not life threatening but it cause physical and mental discomfort, lost
time at work and school.

COMMON OLD, ACUTE RHINITIS AND ALLERGIC RHINITIS.

Common cold is cause by rhinovirus and affects the nasopharyngeal tract. Acute rhinitis, acute
inflammation of the nose mucous membranes accompany common cold. Acute rhinitis often called hay
fever, caused by pollen or foreign substance such as animal dander. Nasal secretions increase in both
acute and allergic rhinitis.

A cold is most contagious 1-4 days before the onset of symptoms (incubation period) and during the
first 3 days of the cold. Transmission by touching, contaminated surfaces and touching the nose/mouth
than it does from contact viral droplets by sneezing.

Drug groups include: antihistamines H1 blockers, decongestants (sympathomimetic amines), antitussive

and expectorants. These drugs can be used singly or in combination preparations.

Colds symptoms: rhinorrhea (watery nasal discharge), nasal congestion, cough and increased mucosal
secretions. If a bacterial infection 2ndary to cold occurs, infectious rhinitis may result, nasal passages
discharge becomes tenacious, mucoid and yellow. Nasal secretions are discolored by WBC and cellular
debris that are by-products of the fight against bacterial infection.
ANTIHISTAMINES: Are H1 blockers or antagonists, compete with histamine receptor sites and prevent a
histamine response. H1 receptor stimulates the smooth muscles lining the nasal cavity are constricted.
When H2 stimulation, increase in gastric secretions, cause peptic ulcer. Antihistamines decrease
nasopharyngeal secretions by blocking the H1 receptor. When used as cold remedies, these agents can
also treat allergic rhinitis. It is not useful in emergency situation such as anaphylaxis. It is rapidly
absorbed in 15 minutes.

1st generation antihistamines cause drowsiness, dry mouth and anticholinergic symptoms. 2 nd generation
have fewer anticholinergic effects and lower incidence of drowsiness. Many OTC cold remedies contain
the 1st generation, so patients must be alerted not to drive or operate dangerous machineries. The
anticholinergic properties of antihistamine causes dry mouth and decreased secretion making them
useful in treating rhinitis caused by common cold. Antihistamines also decrease nasal itching and tickling
cause sneezing. diphenhydramine, is available. Primary use is to treat rhinitis.

Can be IM or IV. Metabolized by the liver and is excreted as metabolites in the urine. It blocks histamine
by competing for and occupying H1 receptor sites. It has anticholinergic effects and should not be used
by patient with narrow-angle glaucoma. Drowsiness is a major side effect. diphenhydramine can be used
as sleep-aid minutes. It can cause CNS depression if taken with alcohol, narcotics, hypnotics or
barbiturates.

Side Effects: drowsiness, dizziness, fatigue, disturbed coordination, rashes, anticholinergic symptoms
such as dry mouth, urine retention, blurred vision and wheezing.

2nd generation are non-sedating antihistamines: cetirizine, desloratadine, and loratadine. Azelastine is
administered by nasal spray. First and second generation antihistamine used to treat allergic rhinitis.

NASAL AND SYSTEMIC DECONGESTANTS: (sympathomimetic amines)

Nasal congestion caused by infection, inflammation or allergy. Stimulate alpha-adrenergic receptors

producing vascular constriction. Result is shrinking mucous membranes and reduction in fluid secretion
(runny nose). Used by nasal spray, drops, tablet, capsule. Frequent use can result in tolerance and
rebound nasal congestion, rebound vasodilation instead of vasoconstriction. Rebound nasal congestion
is caused by irritation of nasal mucosa.

Systemic decongestants (alpha-adrenergic agonists) are used for allergic rhinitis, hay fever and acute
coryza (profuse nasal discharge) examples: tetrahydrozoline, phenylephrine, oxymetazoline (Afrin) and
pseudoephedrine. PPA phenylpropanolamine as ordered by FDA remove from OTC cold remedies and
weight-loss aids. PPA might cause stroke, HTN, RF and cardiac dysrhythmia

Pseudoephedrine is combined with antihistamine, analgesic, or antitussive in oral cold remedies.

Systemic decongestants relieve nasal congestion for longer time than nasal decongestants (fewer SE).
use of nasal decongestants for 3 days could result in rebound nasal congestion. BP and blood glucose
levels can increase. Extra caution in patient with HTN hypertension, cardiac disease, hyperthyroidism
and DM diabetes mellitus. Nurse must emphasize the importance of limiting the use of nasal sprays and
drops.

1st Generation Antihistamines for treatment of Allergic Rhinitis:

Alkylamine derivatives - brompheniramine tannate, chlorpheniramine

Ethanolamine derivatives – clemastine fumarate, diphenhydramine

Piperidine derivatives- cyproheptadine

Piperazine derivative – levocetirizine

Combination: azelastine and fluticasone

2nd generation: azelastine nasal spay, 1-2 sprays in each nostril q12, max 4 spay/day

cetirizine, loratadine, fexofenadine, desloratadine

decongestant can mad a patient nervous or restless, the SE decrease or disappear as the body adjust to
drug

Nursing Process: antihistamine-diphenhydramine. Concept: gas exchange. Assessment: determine

baseline VS. obtain a drug history. Assess for signs and symptoms of urinary disfunction, dysuria, note
complete CBC during therapy, Assess cardiac and respiratory status, obtain environmental exposures,
drugs, recent food eaten, stress

patient problem: hypoxemia, decrease gas exchange, airway obstruction, discomfort

planning: patient will have decreased nasal congestion, mucosal secretions and cough. Patient will sleep
6-8 hours per night

interventions: give oral form of drug with food to decrease gastric distress. Administer IM to large
muscle, avoid SC injection.

Patient teaching: warn to avoid driving, and dangerous activities for drowsiness, avoid alcohol and CNS
depressants, take prescribed drugs only, notify for confusion or hypotension occurs. Breastfeeding is not
recommended while using these drugs.

Evaluation: evaluate effectiveness of the drug in relieving allergic symptoms or as sleep age.

Drugs: oxymetazoline hydrochloride, phenylephrine hydrochloride, pseudoephedrine, tetrahydrozoline

Drug Interactions: pseudoephedrine may decrease the effect of beta-blockers. Taken together with
monoamine oxidase inhibitors MAOIs, decongestants increase HTN or cardiac arrhythmias. Avoid large
amount of caffeine (coffee, tea), increase restlessness and palpitations, caused by decongestants.

INTRANASAL GLUCOCORTICOIDS and steroids are effective for treating allergic rhinitis. They have
inflammatory action, decreasing rhinorrhea, sneezing and congestion.

Steroids : beclomethasone, budesonide, flunisolide, fluticasone, mometasone furoate, triamcinolone

sprays, for rhinitis and asthma, may cause dizziness, HA, fatigue, dyspepsia, nausea, diarrhea, cough,
rhinitis and epistaxis

Drugs may be alone or with H1 antihistamine. Spray directed away from nasal septum, and patient
should sniff gently. Dryness for continuous use.

Prototype Drug Chart: dextromethorphan hydrobromide

Drug Class: Antitussive

Contraindications: hypersensitivity Caution: asthma, bronchitis, HF heart failure, tobacco smoking

Therapeutic effects/uses: relief due especially for non-productive cough due to sore throat, irritation or
common cold. MOA mechanism of Action: decreases excitability of cough center in the medulla.

Side Effects SE: dizziness …

Adverse reactions – psychosis, tachycardia, seizures. Life threatening: respiratory depression,

serotonin syndrome.

Read always the drug label.

ANTITUSSIVE – hard candy may decrease the constant irritating cough, dextromethorphan is a
nonnarcotic that may be taken, 3 types are: nonopioid, opioid, or combination.

Opioid Antitussives: Codeine CSSII, dextromethorphan, guaifenesin and codeine CSS V, homatropine and
hydrocodone CSSIII

Nonopioid : benzonatate

Expectorants: Guaifenesin

Combination of antitussive and Expectorant: guaifenesin and dextromethorphan

Most common expectorant is guaifenesin. Hydration is the best natural expectorant, increase fluid
intake OFI oral fluid intake at least 8 glasses per day.

SINUSITIS -an inflammation of the mucous membranes of one or more of maxillary, frontal, ethmoid or
sphenoid sinuses. Acetaminophen, fluids and rest may be helpful. Antibiotic for acute or severe sinusitis.

ACUTE PHARYNGITIS – sore throat inflammation, cause by virus beta-hemolytic streptococci (step
throat) or other bacteria. Can occur alone or with colds and rhinitis or acute sinusitis. Symptoms of
elevated temperature and cough. Throat culture should be obtained to rule out beta-hemolytic
streptococcal infection. If positive, 10 days of antibiotic. Saline, gargles, lozenges and increase fluid
intake are usually indicated. Acetaminophen may be taken to decrease temperature. Antibiotics are
ineffective for viral pharyngitis.

Nursing Process: patient Centered Collaborative Care

Concept: Gas Exchange Nasal Decongestant: Oxymetazoline

Assessment: Patient Problem: Planning: Nursing Interventions:

Patient Teaching: Evaluation:

You can try to fill up this one.

LOWER RESPIRATORY DISORDERS

COPD, and restrictive lung diseases, compare SE of beta2- adrenergic agonists and methylxanthines,

Describe theophylline level and toxic level

Therapeutic effects of leukotriene, glucocorticoids, cromolyn and antihistamines for COPD and asthma

Apply nursing process.

Chest cavity is close compartment bounded by 12 ribs, diaphragm, thoracic vertebrae, sternum, neck
muscles and intercostal muscles between ribs. Pleurae are membranes that encase the lungs. Lungs are
divided into lobes right 3 and left 2. The heart is not attached to lungs lie on the mid left side in chest
cavity.

Lung compliance is the lung volume based on the pressure in the alveoli. Volume determines the lung’s
ability to stretch. Factors that influence lung compliance are connective tissue (collagen and elastin),
surface tension that is controlled by surfactant. With low compliance, there is decreased lung volume
resulting from increased connective tissue or increased surface tension. The lungs become stiff and
takes greater-than-normal pressure to expand lung tissue.

Oxygen, hydrogen and carbon dioxide in blood influence respiration. Chemoreceptors are sensors that
stimulated by changes in these gases and ions. It is located in the medulla near respiratory center and
CSF, respond to increase CO2 and decrease in pH by increasing ventilation. Carbon dioxide remains
elevated if ventilation is lost.

BRONCHIAL SMOOTH MUSCLE: tracheobronchial tube, becoming more closely spaced as they near the
terminal bronchioles. SNS and PNS affect the bronchial smooth muscle in opposite ways. Vagus nerve
(PNS) release acetylcholine which cause bronchoconstriction. SNS releases epinephrine which stimulates
the beta2 receptor, resulting in bronchodilation. These 2 counterbalance each other to maintain
homeostasis.

Cyclic adenosine monophosphate (cAMP) in the cytoplasm increases bronchodilation by relaxing

bronchial smooth muscles. Phosphodiesterase a pulmonary enzyme can inactivate cAMP. Drugs
methylxanthine group (theophylline) inactivate phosphodiesterase, thus permitting cAMP to function

Drugs are used to alleviate and control airway obstruction. These include the sympathomimetics
(adrenergic) particularly the beta2 adrenergic, methylxanthine such as theophylline, leukotriene
receptor antagonists, glucocorticoids, cromolyn sodium and mucolytics.

4 major pulmonary disorders cause COPD: chronic bronchitis, bronchiectasis, emphysema and asthma
frequently result in irreversible lung tissue damage. Patients with COPD have a decrease forced
expiratory volume in 1 second FEV1, as measured by pulmonary function tests

Restrictive lung disease is a decrease in total lung capacity as a result of fluid accumulation or loss of
elasticity of the lung. Pulmonary edema, pulmonary fibrosis, pneumonitis, lung tumors, thoracic
deformities (scoliosis) and disorders affect the thoracic muscular wall such as myasthenia gravis among
the types.

Draw the overlapping signs and symptoms of COPD conditions.

Bronchial asthma is characterized by bronchospasm(constricted bronchioles), wheezing, mucous

secretions and dyspnea. Chronic bronchitis, emphysema and bronchiectasis, irreversible damage is done
to physical structure of lung tissue. Similar symptoms except wheezing. Steady deterioration over the
period of years.
Hypercapnia (increased carbon dioxide retention) and hypoxemia (decreased blood oxygen) lead to
respiratory acidosis.

Dilation of bronchi and bronchioles is abnormal secondary to frequent infection and inflammation in
bronchiectasis. Tissue fibrosis may result.

Lack of alpha1-antitrypsin protein, that inhibits the proteolytic enzymes destroy the alveoli (air sacs) in
emphysema which is a progressive lung disease caused by cigarette smoking and atmospheric
contaminants. There is no currently known cure for COPD however remains preventable in most cases.
Quit smoking will slow the process.

Medications:

bronchodilators such as sympathomimetics, parasympatholytic (anticholinergic drugs, ipratropium

bromide) and methylxanthine (caffeine, theophylline) are used to assist narrowed airways

glucocorticoids (steroids) to decrease inflammation

leukotriene modifiers reduce inflammation in the lung tissue and cromolyn acts as anti-inflammatory
agent by suppressing the release of histamine and other mediators from mast cells.

Expectorants are used to assist in loosening mucus from airways

Antibiotics may be prescribed to prevent serious complications from bacterial infections.

Prototype drug : albuterol

Drug Class: beta2 adrenergic agonist

Adrenergic Bronchodilators and Anticholinergics

Alpha and beta adrenergic : ephedrine sulfate (alpha1, beta1 beta2)

Epinephrine, revefenacin

Beta- adrenergic: albuterol, formoterol, levalbuterol, metaproterenol sulfate, salmeterol, terbutaline

sulfate, arformoterol tartrate, indacaterol, olodaterol

Anticholinergics : ipratropium bromide, aclidinium, tiotropium, umeclidinium

Monoclonal antibody: omalizumab, reslizumab, duplilumab

Combination of beta and anticholinergics: ipratropium and albuterol

The patient needs to be closely monitored when epinephrine is administered.

Excessive use of aerosol drug can lead to tolerance and loss of drug effectiveness.

Prototype drug: tiotropium drug class: anticholinergic

Anti inflammatory drugs: cromolyn, glucocorticoids (corticosteroids)

Methylxanthine (xanthine) derivatives- 2nd group of bronchodilators used to treat asthma include
aminophylline, theophylline and caffeine.
Theophylline has low therapeutic index and a narrow desired therapeutic range (5-15 mcg/mL) serum
level should be monitored frequently to avoid severe adverse effects. Toxicity occur when > 20mcg/mL
SE: dysrhythmia, seizure and cardiac arrest. Prescribed for maintenance therapy in patient with chronic
stable asthma and COPD when other drugs failed to show improvement. Not to be prescribed with
seizure disorders or cardiac, renal, or liver disease.

Anti-inflammatory drugs for COPD:

Leukotriene modifiers (do not administer for acute asthmatic attack) leukotriene receptor antagonist)
only for prophylactic and maintenance drug therapy for chronic asthma.

zafirlukast

montelukast

leukotriene synthesis inhibitors: zileuton

phosphodiesterase-4 inhibitor : roflumilast

glucocorticoids (corticosteroids) intranasal spray beclomethasone, budesonide, fluticasone …

oral and IV: dexamethasone, hydrocortisone, prednisolone, prednisone

cromolyn- do not use for acute asthmatic attack: cromolyn sodium

combination drugs: glucocorticoid and beta2 agonist: fluticasone and salmeterol

prototype drug; montelukast Drug Class: leukotriene receptor antagonist

Nursing Process: Bronchodilators

Concept: oxygenation

Have your assessment, patient problem, planning, Nursing interventions, patient Teaching, nebulizer
self-administration, diet. Use of MDI, and evaluation.

Cromolyn is used to treat inflammatory effects in pediatrics. Oral glucocorticoids may be prescribed for
young child to control a moderate to severe asthmatic state. An inhalation dose of glucocorticoid should
be 1-2 inhalations 4 times a day.

Drug selection and dosage need to be considered for older adult. Methylxanthines can cause
tachycardia, nervousness and tremors especially those with cardiac conditions. Frequent use of
glucocorticoids can increase patient risk in developing cataracts, osteoporosis and diabetes mellitus. If
theophylline is ordered, dosages of glucocorticoids are decreased.

Antibiotics are used only if bacterial infection results from retained mucous secretions. trimethoprim-
sulfamethoxazole is effective for mild to moderate acute exacerbations of chronic bronchitis AECBs.