RES PIRATORY

DRUGS
 INTRODUCTION

The respiratory tract is divided into

two major parts: the u pper
respiratory tract, which consists of the
nares, nasa.l cavity, pharynx, and
larynx, and the lower
respiratory tract, which consists of
the trachea, bronchi, bronchioles,
alveoli, and alveolar-capillary
membrane.
INTRODUCTION

Air enters through the upper

respiratory tract and travels to
the lower respiratory tract,
where g as exchanges occur.
.
Ventilation is the movement of
air
from the atmosphere through the
upperand lower airways to
alveoli the .

.
Respiration is the process
whereby gas exchange occurs at
the alveolar-capillary membrane.
INTRODUCTION

Air enters through the upper

respiratory tract and travels to
the lower respiratory tract,
where g as exchanges occur.
.
 Phases of
Respiratio
n
1 3
2
VENTILATIO PERFUSION DIFFUSIO
N N
 1 VENTILATIO
N
is the phase in which oxygen passes through the airways. With every inspiration, air
is moved into the lungs, and with every expiration, air is transported out of the
lungs.
 2 PERFUSI
ON
involves blood flow at the alveolar-
capillary bed. Perfusion 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 diffusion of
 3 DIFFUSIO
N
the movement of molecules from
higher to lower concentrations, 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.
LUNG COMPLIANCE
Is the lung volume based on the pressure in the
alveoli.
This volume determines the lung’s ability to
stretch.
Factors that influence lung compliance include:
1. Connective Tissue (collagen and elastin)
2. Surface tension in the alveoli
Control of Respiration
Oxygen (O2), carbon dioxide (CO2), and hydrogen
(H+) ion concentration in the blood influence
respiration.

Chemoreceptors are sensors that are stimulated

by changes in these gases and ions.
Control of Respiration
Central chemoreceptors, located in the medulla near the respiratory
center and cerebrospinal fluid, respond to an increase in CO2 and a
decrease in pH by increasing ventilation.

Peripheral chemoreceptors, located in the carotid and aortic bodies,

respond to changes in oxygen (PO2) levels. A low blood oxygen level
(PO2
 Bronchial Smooth Muscle
The tracheobronchial tube is composed
of smooth muscle whose fibers spiral
around the tracheobronchial tube,
becoming more closely spaced as they
near the terminal bronchioles.

The sympathetic and parasympathetic

nervous systems affect the bronchial
smooth muscle in opposite ways.
UPPER RESPIRATORY
DISORDER
COMMON COLD, ACUTE RHINITIS AND
ALLERGIC RHINITIS
Common cold is caused by the rhinovirus and affects primarily the
nasopharyngeal tract.

Acute rhinitis, acute inflammation of the mucous membranes of the

nose, usually accompanies the common cold.

Allergic rhinitis, often called hay fever, which is caused by pollen or a

foreign substance such as animal dander.
ANTIHISTAMINE
H1 and H2 are the two types of Histamine receptors.

When the H1 receptor is stimulated, the extravascular smooth

muscles including those lining the nasal cavity are constricted.

With stimulation of the H2 receptor, an increase in gastric

secretions occurs, which is a cause of peptic ulcer.

Decrease nasopharyngeal secretions by blocking the H1 receptors.

First-Generation Antihistamines
Most First-generation antihistamines cause drowsiness, Dry mouth
and other anticholinergic symptoms.

Anticholinergic properties of most antihistamine, which can cause

dryness of the mouth and decreased secretions, making them useful
in treating rhinitis caused by the common cold.

Antihistamines also decrease the nasal itching and tickling that cause
sneezing.
Pharmacokinetics
Diphenhydramine can be administered orally, intramuscularly (IM),
or intravenously (IV).

It is well absorbed from the gastrointestinal (GI) tract, but systemic

absorption from topical use is minimal.

It is highly protein bound (98%) and has an average half-life of 2 to 8

hours.

Diphenhydramine is metabolized by the liver and is excreted as

metabolites in the urine.
Pharmacodynamics
Diphenhydramine blocks the effects of histamine by competing for
and occupying H1 receptor sites.

It has anticholinergic effects and should not be used by patients with

narrow-angle glaucoma.

The duration of action is 4 to 7 hours.

Diphenhydramine can cause central nervous system (CNS) depression

if taken with alcohol, narcotics, hypnotics, or barbiturates.
Side effects
The most common side effects of first-generation antihistamines are
drowsiness, dizziness, fatigue, and disturbed coordination.

Skin rashes and anticholinergic symptoms such as dry mouth, urine

retention, blurred vision, and wheezing may also occur.
 PROTOTYPE DRUG CHART: DIPHENHYDRAMINE

1 3
VENTIATION PERFUSION DIFFUSIO
N
Second-Generation Antihistamines
frequently called nonsedating antihistamines because they
have little to no sedative effect.

Used to treat allergic rhinitis.

these antihistamines cause fewer anticholinergic symptoms.

Cetirizine, Fexofenadine, and Loratadine have half-lives

between 7 and 30 hours.

Azelastine is a second-generation antihistamine that has a half-life of 22

hours and is administered by nasal spray.
ANTIHISTAMINE FOR TREATMENT OF ALLERGIC
RHINITIS

2
1 3
VENTIATION PERFUSION DIFFUSIO
N
ANTIHISTAMINE FOR TREATMENT OF ALLERGIC
RHINITIS

2
1 3
VENTIATION PERFUSION DIFFUSIO
N
ANTIHISTAMINE FOR TREATMENT OF ALLERGIC
RHINITIS

2
1 3
VENTIATION PERFUSION DIFFUSIO
N
NURSING PROCESS

Antihistamine: Diphenhydramine
Assessment:
• Determine baseline vital signs.
• Obtain a drug history, and report if a drug-drug interaction is probable.
• Assess for signs and symptoms of urinary dysfunction, including
retention, dysuria, and altered frequency.
• Note complete blood count (CBC) during drug therapy.
• Assess cardiac and respiratory status.
• Obtain a history of environmental exposures that includes drugs, recent
foods eaten, and stress.
NURSING PROCESS

Antihistamine: Diphenhydramine
Nursing Diagnoses:
• Airway Clearance, Ineffective related to nasal congestion
• Fluid Volume, Risk for Imbalanced
• Sleep Deprivation related to frequent coughing

Planning:
• Patient will have decreased nasal congestion, mucosal secretions, and
cough.
• Patient will sleep 6 to 8 hours per night.
NURSING PROCESS

Antihistamine: Diphenhydramine
Nursing Interventions:

• Give the oral form of the drug with food to

decrease gastric distress.
• Administer the intramuscular form in a
large muscle. Avoid subcutaneous injection
NURSING PROCESS
Antihistamine: Diphenhydramine
Patient teaching:
NURSING PROCESS
Antihistamine: Diphenhydramine
Patient teaching:
NURSING PROCESS

Antihistamine: Diphenhydramine

EVALUATION:

• Evaluate effectiveness of the drug in relieving allergic symptoms or as a sleep

aid.
NASAL AND SYSTEMIC DECONGESTANTS
Nasal Congestions results from dilation of nasal blood vessels caused by infection,
inflammation, or allergy.

With this dilation, a transudation of fluid into the tissue spaces occurs that results
in swelling of the nasal cavity.

Nasal decongestants (sympathomimetic amines) stimulate the alpha-adrenergic

receptors, producing vascular constriction (vasoconstriction) of the capillaries
within the nasal mucosa.

The result is shrinking of the nasal mucous membranes and a reduction in fluid
secretion (runny nose).
NASAL AND SYSTEMIC DECONGESTANTS

Systemic decongestants (alpha-adrenergic agonists) are available in

tablet, capsule, and liquid form and are used primarily for allergic
rhinitis, including hay fever and acute coryza (profuse nasal discharge)

Examples of systemic decongestants are ephedrine, phenylephrine,

oxymetazoline (Afrin), and pseudoephedrine.
Nasal and Systemic Decongestants
(sympathomimetic Amines)

2
1
Side effects and Adverse Reaction
The incidence of side effects is low with topical preparations such as nose drops.
However, decongestants can make a patient jittery, nervous, or restless.

Use of nasal decongestants for as little as 3 days could result in rebound nasal
congestion.

As with any alpha-adrenergic drug such as decongestants, blood pressure and

blood glucose levels can increase.

These drugs are contraindicated or used with extreme caution in patients with
hypertension, cardiac disease, hyperthyroidism, and diabetes mellitus.
Drug Interactions
Pseudoephedrine may decrease the effect of beta blockers.

Taken together with monoamine oxidase inhibitors (MAOIs),

decongestants may increase the possibility of hypertension or cardiac
dysrhythmias.

The patient should also avoid large amounts of caffeine (coffee, tea)
because it can increase restlessness and palpitations caused by
decongestants.
INTRANASAL GLUCOCORTICOIDS
Intranasal glucocorticoids and steroids are effective for treating
allergic rhinitis because they have an anti-inflammatory action, thus
decreasing the allergic rhinitis symptoms of rhinorrhea, sneezing,
and congestion.

Examples of intranasal steroids:

• Beclomethasone
• Budesonide 979
• Dexamethasone
• Flunisolide
• Fluticasone
• Mometasone
• Triamcinolone
ANTITUSSIVES
act on the cough-control center in the medulla to suppress the cough reflex.

The cough is a naturally protective way to clear the airway of secretions or any
collected material.

A sore throat may cause coughing that increases throat irritation.

Hard candy may decrease the constant, irritating cough. Guaifenesin, a

nonnarcotic antitussive, is widely used in OTC cold remedies.

The three types of antitussives are nonopioid, opioid, or combination

preparations. Antitussives are usually used in combination with other agents
ANTITUSSIVES
act on the cough-control center in the medulla to suppress the cough
reflex.

The cough is a naturally protective way to clear the airway of

secretions or any collected material.

A sore throat may cause coughing that increases throat irritation.

Hard candy may decrease the constant, irritating cough. Guaifenesin,

a nonnarcotic antitussive, is widely used in OTC cold remedies.
Pharmacokinetics
Dextromethorphan is available in numerous cold and cough remedy
preparations in syrup or liquid form, chewable capsules, and lozenges.

The drug is rapidly absorbed and exerts its effects 15 to 30 minutes after
oral administration.

Its protein-binding percentage is unknown, and the half-life is 1 hour.

Dextromethorphan is metabolized by the liver and is excreted in the urine.

Pharmacodynamics
Dextromethorphan, an expectorant, reduces the
viscosity of tenacious secretions.

This drug also acts as a nonopioid antitussive by

changing a nonproductive cough to a less frequent,
productive cough.
DEXTROMETHORPHAN HYDROBROMIDE

1 3
VENTIATION PERFUSION DIFFUSIO
N
EXPECTORANTS
loosen bronchial secretions so they can be eliminated by coughing.

They can be used with or without other pharmacologic agents.

Expectorants are found in many OTC cold remedies along with

analgesics, antihistamines, decongestants, and antitussives.

The most common expectorant in such preparations is guaifenesin.

NURSING PROCESS

Common Cold
Assessment:
 Determine whether the patient has a history of hypertension,
especially if a decongestant is an ingredient in the cold remedy being
taken.

 Note baseline vital signs.

 Obtain a drug history, and report if a drug-drug interaction is probable.

 Assess cardiac and respiratory status.

NURSING PROCESS

Common Cold
NURSING DIAGNOSES:
Airway Clearance, Ineffective related to nasal
congestion
 Fluid Volume, Risk for Imbalanced
Sleep Deprivation related to chronic coughing
Fatigue related to sleep deprivation
Infection, Risk for
NURSING PROCESS

Common Cold
PLANNING:
Patient’s cough will be eliminated or diminished.
Patient will be free from a secondary bacterial
infection. Nursing Interventions.
NURSING PROCESS

Common Cold
NURSING INTERVENTION:
 Monitor vital signs. Blood pressure can become elevated when a decongestant is
taken, and dysrhythmias can also occur.

 Observe the color of bronchial secretions. Yellow or green mucus is indicative of

a bronchial infection. Antibiotics may be needed.

 Warn patients that codeine preparations for cough suppression can lead to
tolerance and physical dependence.
NURSING PROCESS

Common Cold
Patient Teaching:
 Tell patients that hypotension and hyperpyrexia may occur when
dextromethorphan is taken with MAOIs.
 Teach patients about proper use of nasal sprays and proper use of “puff”
or squeeze products.
 Caution patients not to use more than one or two puffs four to six times
a day for 5 to 7 days, because rebound congestion can occur with
overuse.
NURSING PROCESS

Common Cold
Patient Teaching:
 Advise patients to read labels on OTC drugs and to check with a health
care provider before taking cold remedies.

 Inform patients that antibiotics are not helpful in treating common cold
viruses.

 Encourage older patients with heart disease, asthma, emphysema,

diabetes mellitus, or hypertension to contact a health care provider
concerning the selection of drug, including OTC drugs.
NURSING PROCESS

Common Cold
Patient Teaching:
 Direct patients not to drive during initial use of a cold remedy containing
an antihistamine because drowsiness is common.

 Tell patients to maintain adequate fluid intake. Fluids liquefy bronchial

secretions to ease elimination with coughing.

 Teach patients not to take a cold remedy before or at bedtime. Insomnia

may occur if it contains a decongestant.
NURSING PROCESS

Common Cold
Self-administration:
 Teach patients to self-administer medications such as nose drops and
inhalants.
 Encourage patients to cough effectively, to take deep breaths before
coughing, and to be in an upright position.

Evaluation:
 Evaluate effectiveness of drug therapy. Determine that the patient is free
from nonproductive cough, has adequate fluid intake and rest, and is
afebrile.
SINUSITIS
is an inflammation of the mucous membranes of one or more of the
maxillary, frontal, ethmoid, or sphenoid sinuses.

A systemic or nasal decongestant may be indicated. Acetaminophen, fluids,

and rest may also be helpful. For acute or severe sinusitis, an antibiotic may
be prescribed.
ACUTE PHARYNGITIS
Inflammation of the throat or “sore throat,” can be caused by a virus,
betahemolytic streptococci (“strep throat”), or other bacteria.

It can occur alone or with the common cold and rhinitis or acute sinusitis.
Symptoms include elevated temperature and cough.

A throat culture should be obtained to rule out beta-hemolytic streptococcal

infection.

Saline gargles, lozenges, and increased fluid intake are usually indicated.
Acetaminophen may be taken to decrease elevated temperature.
Antibiotics are not effective for viral pharyngitis.
LOWER RESPIRATORY
DISORDER
LOWER RESPIRATORY DISORDERS

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Is caused by the airway obstruction with increased airway resistance
of airflow to the lung tissues.
Four Major pulmonary disorder cause COPD:
1. Chronic Bronchitis
2. Bronchiectasis
3. Emphysema
4. Asthma
LOWER RESPIRATORY DISORDERS

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 that affect the thoracic
muscular wall, such as myasthenia gravis, are among the types and
causes of restrictive pulmonary disease.
 CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
ASTHMA - is an inflammatory disorder of the airway walls associated
with a varying amount of airway obstruction.

is triggered by stimuli such as stress, allergens, and pollutants.

Inflammation aggravates airway hyperresponsiveness to stimuli,

causing bronchial cells to produce more mucus, which obstructs air
passages.
 CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
BRONCHIAL ASTHMA
is characterized by bronchospasm (constricted bronchioles), wheezing,
mucous secretions, and dyspnea.
There is resistance to airflow caused by obstruction of the airway.
 CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
CHRONIC BRONCHITIS
is a progressive lung disease caused by smoking or chronic lung infections.
Bronchial inflammation and excessive mucous secretion result in airway
obstruction.

Productive coughing is a response to excess mucous production and

chronic bronchial irritation
 CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
BRONCHIECTASIS
Dilation of the bronchi and bronchioles is abnormal secondary to frequent
infection and inflammation.
 CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
Emphysema
is a progressive lung disease caused by cigarette smoking,
atmospheric contaminants, or lack of the alpha1-antitrypsin protein
that inhibits proteolytic enzymes that destroy alveoli (air sacs).
 CHRONIC OBSTRUCTIVE PULMONARY
DISEASE

CIGARETTE SMOKING is the most common risk factor for COPD,

especially with chronic bronchitis and emphysema.
MEDICATIONS FREQUENTLY PRESCRIBED FOR COPD:

• Bronchodilators such as sympathomimetics (adrenergics),

parasympatholytics (anticholinergic drugs, ipratropium bromide), and
methylxanthines (caffeine, theophylline) are used to assist in opening
narrowed airways.

• Glucocorticoids (steroids) are used to decrease inflammation.

MEDICATIONS FREQUENTLY PRESCRIBED FOR COPD:

• Leukotriene modifiers reduce inflammation in the lung tissue, and

cromolyn acts as an anti-inflammatory agent by suppressing the
release of histamine and other mediators from the mast cells.
• Expectorants are used to assist in loosening mucus from the
airways.
• Antibiotics may be prescribed to prevent serious complications
from bacterial infections.
 BRONCHIAL ASTHMA
is a COPD characterized by periods of bronchospasm resulting in
wheezing and difficulty breathing.

Bronchospasm, or bronchoconstriction, results when the lung tissue

is exposed to extrinsic or intrinsic factors that stimulate a
bronchoconstrictive response.
BRONCHIAL ASTHMA
BRONCHIAL ASTHMA
 SYMPATHOMIMETICS:
Alpha- and Beta2 -Adrenergic Agonists

Sympathomimetics increase cAMP, causing dilation of the

bronchioles.

In an acute bronchospasm caused by anaphylaxis from an

allergic reaction, the nonselective sympathomimetic
epinephrine - an alpha1 , beta1 , and beta2 agonist—is given
subcutaneously to promote bronchodilation and elevate blood
pressure.
 SYMPATHOMIMETICS:
Alpha- and Beta2 -Adrenergic Agonists

For bronchospasm associated with chronic asthma or COPD,

selective beta2-adrenergic agonists are given by aerosol or as a
tablet.

These drugs act primarily on the beta2 receptors, therefore

side effects are less severe than those of epinephrine, which
acts on alpha1 , beta1 , and beta2 receptors.
 ALBUTEROL
is a selective beta2 drug that is effective for treatment and
control of asthma by causing bronchodilation with a long
duration of action.

High doses or overuse of the beta2-adrenergic agents for

asthma may cause some degree of beta1 response, such as
nervousness, tremor, and increased pulse rate.
 METAPROTERENOL
is primarily used as a beta2 agent but has some beta1 effect.

It can be administered orally or by inhalation with a metered-

dose inhaler (MDI) or a nebulizer.

For long-term asthma treatment, beta2-adrenergic agonists

are frequently administered by inhalation.
 METAPROTERENOL
is primarily used as a beta2 agent but has some beta1 effect.

It can be administered orally or by inhalation with a metered-

dose inhaler (MDI) or a nebulizer.

For long-term asthma treatment, beta2-adrenergic agonists

are frequently administered by inhalation.
Adrenergic bronchodilators
Adrenergic bronchodilators
 ANTICHOLINEGRICS

Tiotropium is an anticholinergic drug used for maintenance

treatment of bronchospasms associated with COPD.

This drug is administered by inhalation only with the

HandiHaler device (dry-powder capsule inhaler).
 ANTICHOLINEGRICS

Adverse effect of Tiotropium include dry mouth, constipation,

vomiting, dyspepsia, abdominal pain, depression, insomnia,
headache, joint pain, and peripheral edema.

Chest pain has been reported following tiotropium

administration.
TIOTROPIUM
 ANTICHOLINEGRICS

Ipratropium bromide is used to treat asthmatic conditions by

dilating the bronchioles.

Unlike other anticholinergics, ipratropium bromide has few

systemic effects.

It is administered by MDI.
 ANTICHOLINEGRICS
Combination of Ipratropium Bromide with Albuterol is used to
treat COPD.

is more effective and has a longer duration of action than either

agent used alone.

These two agents combined increase the FEV1, the index used
to evaluate asthma and obstructive lung disease and the
patient’s response to bronchodilator therapy.
Anticholinergics
Combination Beta-Adrenergics and
Anticholinergics
 METHYLXANTHINE (XANTHINE)
DERIVATIVES
The second major group of bronchodilators used to treat
asthma, which include aminophylline, theophylline, and
caffeine.

also stimulate the central nervous system (CNS) and

respiration, dilate coronary and pulmonary vessels, and cause
diuresis.
 METHYLXANTHINE (XANTHINE)
DERIVATIVES
THEOPHYLLINE
relaxes the smooth muscles of the bronchi, bronchioles, and
pulmonary blood vessels by inhibiting the enzyme
phosphodiesterase, resulting in an increase in cAMP, which
promotes bronchodilation.
 Pharmacokinetics
THEOPHYLLINE
Is usually well absorbed after oral administration, but absorption may vary
according to the specific dosage form.

is also well absorbed from oral liquids and uncoated plain tablets. Sustained-
release dosage forms are slowly absorbed.

Food and antacids may decrease the rate but not the extent of absorption;
large volumes of fluid and high-protein meals may increase 999 the rate of
absorption.

The dose size can also affect the rate of absorption: larger doses are
absorbed more slowly.
 Pharmacokinetics
THEOPHYLLINE

in smokers and children, the half-life is 4 to 5 hours, and the dose

requirement may be increased.

In premature infants, the half-life is 9.4 to 43 hours.

In patients with heart failure (HF), cor pulmonale, COPD, or liver disease,
the half-life is 24 hours.

Kidney function may be decreased in older adults, so caution should be used

regarding the theophylline dosage to avoid drug toxicity.
 Pharmacodynamics
THEOPHYLLINE

increases the level of cAMP, resulting in bronchodilation.

Average onset of action is 30 minutes for oral preparations and 1 to 2 hours

for sustained-release (SR) capsules.

The peak action is 30 minutes for IV administration and 1 to 2 hours when

taken orally.
 Side Effects and Adverse Reaction
THEOPHYLLINE

Anorexia, Nausea and Vomiting, Gastric pain, Intestinal bleeding,

nervousness, Dizziness, Headache, Irritability, cardiac dysrhythmias,
tachycardia, palpitations, marked hypotension, hyperreflexia, and
seizures.

Adverse CNS reactions—headaches, irritability, restlessness,

nervousness, insomnia, dizziness, and seizures—are often more
severe in children than in adults.
 Side Effects and Adverse Reaction
THEOPHYLLINE

Theophylline toxicity is most likely to occur when serum concentrations

exceed 20 mcg/mL.

Theophylline can cause hyperglycemia, decreased clotting time, and, rarely,

increased white blood cell count (leukocytosis).

Theophylline can cause hyperglycemia, decreased clotting time, and, rarely,

increased white blood cell count (leukocytosis).

Rapid IV administration of aminophylline, a theophylline product, can cause

dizziness, flushing, hypotension, severe bradycardia, and palpitations.
 Drug Interactions
THEOPHYLLINE

Beta blockers, cimetidine, propranolol, and erythromycin decrease the liver

metabolism rate and increase the half-life and effects of theophylline;
barbiturates and carbamazepine decrease its effects.

Theophylline increases the risk of digitalis toxicity and decreases the effects
of lithium.

Phenytoin decreases theophylline levels. If theophylline and a beta-

adrenergic agonist are given together, a synergistic effect can occur that can
result in cardiac dysrhythmias.
NURSING PROCESS
BRONCHODILATORS
Assessment:
• Obtain a medical and drug history; report probable drug-drug interactions.
• Note baseline vital signs and pulse oximetry for abnormalities and future
comparisons.
• Assess for wheezing, decreased breath sounds, cough, and sputum production.
• Assess sensorium for confusion and restlessness caused by hypoxia and
hypercapnia.
• Determine hydration; diuresis may result in dehydration in children and older
adults.
• Assess serum theophylline levels. Toxicity occurs at a higher frequency with levels
greater than 20 mcg/mL.
NURSING PROCESS
BRONCHODILATORS
NURSING DIAGNOSIS

• Breathing Pattern, Ineffective related to fatigue

• Airway Clearance, Ineffective related to retained secretions in the bronchi
• Gas Exchange, Impaired related to ineffective airway clearance
• Noncompliance with drug therapy related to inadequate financial
resources
• Activity Intolerance related to fatigue and an imbalance between oxygen
supply and demand
NURSING PROCESS
BRONCHODILATORS
PLANNING

• The patient will be free from wheezing, and lung

fields will be clear within 2 to 5 days.
• The patient will self-administer oral drugs and will
use an inhaler as prescribed.
NURSING PROCESS
BRONCHODILATORS
NURSING INTERVENTION

• Monitor vital signs. Blood pressure and heart rate can increase
greatly. Check for cardiac dysrhythmias.
• Provide adequate hydration. Fluids help loosen secretions.
• Monitor drug therapy.
• Observe for side effects.
NURSING PROCESS
BRONCHODILATORS
NURSING INTERVENTION

• Administer medication after meals to decrease gastrointestinal (GI)

distress.
• Administer medication at regular intervals around the clock to have a
sustained therapeutic level.
• Do not crush enteric-coated (EC) or sustained-released (SR) tablets or
capsules.
• Check serum theophylline levels (normal level is 5-15 mcg/mL).
NURSING PROCESS
BRONCHODILATORS
PATIENT TEACHING : GENERAL

• Teach patients to monitor their pulse rate.

• Encourage patients to monitor the amount of medication remaining in
the canister.
• Advise patients not to take over-the-counter (OTC) preparations without
first checking with a health care provider. Some OTC products may have an
additive effect.
• Encourage patients contemplating pregnancy to seek medical advice
before taking a theophylline preparation.
NURSING PROCESS
BRONCHODILATORS
PATIENT TEACHING : GENERAL

• Advise patients to avoid smoking.

• Discuss ways to alleviate anxiety, such as relaxation techniques and
music.
• Advise patients having asthmatic attacks to wear an identification
bracelet or MedicAlert tag.
• Inform patients that certain complementary and alternative therapies
may interact with theophylline.
NURSING PROCESS
BRONCHODILATORS
PATIENT TEACHING : SELF-ADMINISTRATION

• Teach patients to correctly use the inhaler or nebulizer.

• Teach patients to monitor pulse rate and report to a health care provider
any irregularities in comparison with baseline values.
NURSING PROCESS
BRONCHODILATORS
PATIENT TEACHING : DIET

• Advise patients that a high-protein, low-carbohydrate diet increases

theophylline elimination. Conversely, a low-protein, high-carbohydrate diet
prolongs half-life; dosage may need adjustment.
NURSING PROCESS
NURSING PROCESS
BRONCHODILATORS
EVALUATION

• Evaluate the effectiveness of the bronchodilator. The patient should

be breathing without wheezing and should be unharmed from the
side effects of the drug.

• Determine serum theophylline levels to ensure a therapeutic range.

LEUKOTRIENE RECEPTOR ANTAGONIST
AND SYNTHESIS INHIBITORS

Leukotriene (LT) is a chemical mediator that can cause

inflammatory changes in the lung.

The Cysteinyl leukotrienes promote an increase in eosinophil

migration, mucous production, and airway wall edema that
results in bronchoconstriction.
LEUKOTRIENE RECEPTOR ANTAGONIST
AND SYNTHESIS INHIBITORS

LT receptor antagonists and LT synthesis inhibitors, called

leukotriene modifiers, are effective in reducing the
inflammatory symptoms of asthma triggered by allergic and
environmental stimuli.

Three leukotriene modifiers: Zafirlukast, Zileuton, and

Montelukast—are available in the United States.
NURSING PROCESS
LEUKOTRINE RECEPTOR ANTAGONISTS
Assessment:

• Obtain a medical, drug, and herbal history; report probable drug-

drug or drug-herb interactions.
• Note baseline vital signs for identifying abnormalities and for
future comparisons.
• Assess for wheezing, decreased breath sounds, cough, and sputum
production.
NURSING PROCESS
LEUKOTRINE RECEPTOR ANTAGONISTS
Assessment:
• Assess sensorium for confusion and restlessness caused by hypoxia and
hypercapnia.

• Assess for a history of phenylketonuria when montelukast is prescribed

because children’s chewable tablets contain phenylalanine.

• Determine hydration; diuresis may result in dehydration in children and

older adults.
NURSING PROCESS
LEUKOTRINE RECEPTOR ANTAGONISTS
NURSING DIAGNOSES

• Airway Clearance, Ineffective related to retained secretions in bronchi

• Activity Intolerance related to imbalance between oxygen supply and

demand

• Knowledge, Deficient of OTC drug interaction related to lack of exposure

to information
NURSING PROCESS
LEUKOTRINE RECEPTOR ANTAGONISTS
PLANNING

• The patient will be free from wheezing, or wheezing will have significantly
improved.

• The patient’s lung fields will be clear within 2 to 5 days.

• The patient will take medications as prescribed.

NURSING PROCESS
LEUKOTRINE RECEPTOR ANTAGONISTS
PATIENT TEACHING: GENERAL

• Advise patients that if an allergic reaction occurs (i.e., rash, urticaria), the
drug should be discontinued and a health care provider should be notified.
• Monitor hepatic function tests periodically.
• Direct patients not to take St. John’s wort without first checking with a
health care provider because this product may decrease montelukast
concentration.
• Warn patients that black or green tea and guarana taken with
montelukast and zafirlukast may cause increased stimulation.
NURSING PROCESS
LEUKOTRINE RECEPTOR ANTAGONISTS
PATIENT TEACHING: GENERAL

• Encourage patients to stop smoking.

• Discuss ways to alleviate anxiety (relaxation techniques, music).
• Advise patients who have frequent or severe asthmatic attacks to wear an
identification bracelet or a MedicAlert tag.
• Encourage patients contemplating pregnancy to seek medical advice before
taking montelukast.
• Caution patients and their significant others not to open oral granule packets
until they are ready to use them.
• Advise patients with known aspirin sensitivity to avoid a bronchoconstrictor
response by avoiding aspirin and nonsteroidal antiinflammatory drugs (NSAIDs)
while taking montelukast.
NURSING PROCESS
LEUKOTRINE RECEPTOR ANTAGONISTS
PATIENT TEACHING: SELF-ADMINISTRATION
• Teach patients not to use montelukast for reversal of an acute asthmatic
attack because it is only recommended for prevention of acute attacks and
for treatment of chronic asthma.
• Advise patients to continue to use the usual regimen of inhaled
prophylaxis and short-acting rescue medication for exercise-induced
bronchospasm.
• Encourage patients to inform a health care provider if short-acting
inhaled bronchodilators are needed more often than usual with
montelukast.
NURSING PROCESS
LEUKOTRINE RECEPTOR ANTAGONISTS
PATIENT TEACHING: SELF-ADMINISTRATION

• Tell patients to comply with the medication regimen even during

symptom-free periods.
• Advise patients, especially children, that chewable tablets are to be
chewed thoroughly because swallowing whole may alter absorption.
NURSING PROCESS
LEUKOTRINE RECEPTOR ANTAGONISTS
PATIENT TEACHING: DIET

• Tell patients to take leukotriene receptor antagonists in the evening for

maximum effectiveness.
NURSING PROCESS
LEUKOTRINE RECEPTOR ANTAGONISTS
EVALUATION

• Evaluate the effectiveness of the bronchodilators. The patient should be

breathing without wheezing and without side effects of the drug.

• Evaluate tolerance to activity.

 GLUCOCORTICOIDS (STEROIDS)

Members of the corticosteroid family, are used to treat

respiratory disorders, particularly asthma.

These drugs have an anti-inflammatory action and are

indicated if asthma is unresponsive to bronchodilator therapy
or if the patient has an asthmatic attack while on maximum
doses of theophylline or an adrenergic drug.

It is thought that glucocorticoids have a synergistic effect when

given with a beta2 agonist.
 GLUCOCORTICOIDS (STEROIDS)

Glucocorticoids can be given using the following methods:

• MDI inhaler: Beclomethasone

• Tablet: Dexamethasone, prednisone
• Intravenous: Dexamethasone
 GLUCOCORTICOIDS (STEROIDS)

Inhaled glucocorticoids are not helpful in treating a severe

asthmatic attack because it may take 1 to 4 weeks for an
inhaled steroid to reach its full effect.

The use of an oral inhaler minimizes the risk for adrenal

suppression associated with oral systemic glucocorticoid
therapy.

Inhaled glucocorticoids are preferred over oral preparations

unless they fail to control the asthma.
 GLUCOCORTICOIDS (STEROIDS)

Prednisone, prednisolone, dexamethasone, or

methylprednisolone—for management of moderate to severe
asthma exacerbations.

Oral or IV administration of methylprednisolone 40 to 80 mg

per day in 1 to 2 divided doses may be given for 3 to 10 days.

a single dose or short-term use, glucocorticoids may be

discontinued abruptly after symptoms are controlled.
 GLUCOCORTICOIDS (STEROIDS)

Glucocorticoids can irritate the gastric mucosa and should be

taken with food to avoid ulceration.

A combination inhalation drug containing the glucocorticoid

fluticasone propionate and salmeterol is effective in controlling
asthma symptoms by alleviating airway constriction and
inflammation.
SIDE EFFECTS AND ADVERSE REACTION

Side effects associated with orally inhaled glucocorticoids are

generally local (e.g., throat irritation, hoarseness, dry mouth,
coughing) rather than systemic.

Oral, laryngeal, and pharyngeal fungal infections have occurred

but can be reversed with discontinuation and antifungal
treatment.
SIDE EFFECTS AND ADVERSE REACTION

Candida albicans oropharyngeal infections, headache,

euphoria, confusion, sweating, hyperglycemia, insomnia,
nausea, vomiting, weakness, and menstrual irregularities.

Adverse effects include depression, peptic ulcer, loss of bone

density and development of osteoporosis, and psychosis
SIDE EFFECTS AND ADVERSE REACTION

When oral and IV steroids prolonged periods, electrolyte

imbalance, fluid retention (puffy eyelids, edema in the lower
extremities, moon face, weight gain), hypertension, thinning of
the skin, purpura, abnormal subcutaneous fat distribution,
hyperglycemia, and impaired immune response are likely to
occur.
 GLUCOCORTICOIDS (STEROIDS)

Intranasal Spray
• Beclomethasone
• Qvar
• Budesonide
• Flunisolide
• Fluticasone
• Mometasone
furoate
• Triamcinolone
 GLUCOCORTICOIDS (STEROIDS)

Aerosol inhalation
• BeclomethasoneFlunisolide
• Budesonide
• fluticasone
 GLUCOCORTICOIDS (STEROIDS)

Oral and Intravenous Administration

Cortisone acetate
Dexamethasone
Fludrocortisone acetate
Hydrocortisone
Methylprednisolone
Prednisolone
Prednisone
GLUCOCORTICOIDS (STEROIDS)
 CROMOLYN

is used for prophylactic treatment of bronchial asthma, and it

must be taken daily. It is not used for acute asthmatic attacks.

Cromolyn does not have bronchodilator properties but instead

acts by inhibiting release of histamine and other inflammatory
mediators from mast cells to prevent an asthma attack.
 CROMOLYN

Most common side effects include postnasal drip, irritation of

the nose and throat, and a cough. These effects can be
decreased by drinking water before and after using the drug.

Cromolyn is administered by oral inhalation via MDI or

nebulizer and nasal inhalation via metered spray.

It can be used with beta adrenergics and xanthine derivatives.

Rebound bronchospasm is a serious side effect of cromolyn..
CROMOLYN
 DRUG THERAPY FOR ASTHMA
ACCCORDING TO SEVERITY

Chronic asthma may be controlled through a long-term medical

treatment program and by a quickrelief program during an
acute phase.

The long-term program may vary according to the symptoms of

the asthma and its severity, whereas the quick-relief therapy is
the same for all classes of asthma.
 DRUG THERAPY FOR ASTHMA
ACCCORDING TO AGE
Young Children

Cromolyn is used to treat the inflammatory effects of asthma in

children.

Oral glucocorticoids may be prescribed for the young child to

control a moderate to severe asthmatic state.

An inhalation dose of a glucocorticoid should be about 1 to 2

inhalations 4 times a day.
 DRUG THERAPY FOR ASTHMA
ACCCORDING TO AGE
Older Adult

Beta2-adrenergic agonists and methylxanthines such as

theophylline can cause tachycardia, nervousness, and tremors
in older adults, especially those with cardiac conditions.

Frequent use of glucocorticoids can increase the risk of the

patient developing cataracts, osteoporosis, and diabetes
mellitus. If a theophylline drug is ordered, dosages of
glucocorticoids are normally decreased.
 MUCOLYTICS

Act as detergents to liquefy and loosen thick, mucous

secretions so they can be expectorated.

Acetylcysteine is administered by nebulization for

bronchopulmonary disorders. With one important exception,
this drug should not be mixed with other drugs.

Side effects include nausea and vomiting, stomatitis (oral

ulcers), and “runny nose.”
 MUCOLYTICS

Dornase alfa is an enzyme that digests deoxyribonucleic acid

(DNA) in thick sputum secretions of patients with cystic fibrosis
(CF).

This agent helps reduce respiratory infections and improves

pulmonary function; such improvement usually occurs in 3 to 7
days with its use. Side effects include chest pain, sore throat,
laryngitis, and hoarseness.
 ANTIMICROBIAL

Antibiotics are 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
(AECBs) from infectious causes.
If you woke up breathing,
Congratulation! You have another
chance. –Andrea Boydston