Ch. 18 (Pharm)

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Terms in this set (...)

Obstructive Lung Disease (can't get the air out):
• Narrowed airways (e.g., asthma, chronic bronchitis)
• Destroyed alveoli (e.g., emphysema)
Restrictive Lung Disease (can't get the air in):
- Pulmonary fibrosis
- Pneumonitis
- Lung tumors
- Thoracic deformities (scoliosis)
- Myasthenia gravis
Chronic obstructive pulmonary disease:
(COPD) - includes chronic bronchitis and emphysema
COPD: Chronic Bronchitis
• Inflammation of the lower airways
• characterized by excessive secretion of mucus, hypertrophy of mucous glands, and recurring infection
• progresses to narrowing and obstruction of airflow
• can be caused by smoking, infections, frequent bronchitis)
COPD: Emphysema
• Abnormal, irreversible enlargement of air spaces distal to terminal bronchioles
• due to destruction of alveolar walls, resulting in decreased elastic recoil properties of lungs.
• Characterized by air trapped in the alveoli resulting in inadequate gas exchange
• Can be caused by smoking, atmospheric pollutants
Asthma:
• Involves airway inflammation, intermittent airflow obstruction, and bronchial hyper-responsiveness.
• Episodic (exacerbations) symptoms of airflow obstruction are present; problems are intermittent and reversible
• Airflow obstruction or symptoms are at least partially reversible

• Manifestations: Bronchospasm (airways narrow); Wheezing; Mucus secretions; Dyspnea
Drug Therapy:
• Bronchodilators
• Anticholinergics
• Anti-inflammatory Drugs
• Leukotriene Inhibitors
• Phosphodiesterase-4 (PDE4) inhibitors
• Mucolytics
Bronchodilators
• Mechanism of action: relax smooth muscle; have no effect on inflammation
Bronchodilators: Intended Responses
• Intended responses: pulmonary smooth muscles relax; airways widen, allowing air to move more freely into and out of the alveoli; wheezing decreases or disappears; PERF increases compared with readings taken right before drug therapy
Bronchodilators: Side effects
• Side effects: tachycardia, hypertension, dry mouth and throat, tremors, feeling of nervousness, difficulty sleeping, leave bad taste in the mouth / if the anticholinergic agents reach the bloodstream you could experience urinary retention, blurred vision, eye pain, nausea, and headache
Bronchodilators: adverse effects
• Adverse effects: minor-to-severe allergic reactions; if the patient use the drug more than prescribed, enough drug can reach the blood to cause the blood vessels in the heart to constrict, leading to angina or MI
Beta2-adrenergic agonists (Bronchodilators):
• bind to the beta2-adrenergic receptors and cause an increase in the production of a substance (cAMP) that triggers pulmonary smooth muscle relaxation
Short-acting Beta2-agonists (SABAs) (Bronchodilators):
- (Rescue Drugs); provide rapid but short-term relief; used for COPD when the person feels more breathless than usual; when inhaled, the drug is delivered directly to the lungs, and systemic effects are minimal
• Albuterol: very common; rapid onset (good immediate symptom relief); effects last about 3-6 hours
• Levalbuterol: rapid acting, shorter duration
• Terbutaline
Long-acting Beta2-agonists (LABAs) (Bronchodilators):
- (Prevention drugs); for persistent symptoms; long period of duration (10-12 hours); not immediate onset, need time to build up an effect; for COPD these drugs are taken daily to maintain open airways
• Arformoterol
• Salmeterol

• In most cases, patient taking a LABA should also be taking a glucocorticoid for long-term suppression of inflammation (asthma patients)
Methylxanthine (Bronchodilators):
- given systemically rather than by inhaler; bronchodilation; used only when other types of management are ineffective; have many side effects
• aminophylline — theophylline
- Administration: oral, IV
- Side effects: nervousness, irritability, insomnia, flushed, dizziness, GI distress, tachycardia, palpitations
- Adverse effects: methylxanthines can increase HR and BP, cause sever seizures, life-threatening dysrhythmias (more likely to occur when given IV but can occur when taken orally); cardiopulmonary collapse and arrest
• Therapeutic range: 10 to 20 mcg/mL (toxicity greater than 20)
Anticholinergics:
- block the parasympathetic nervous system; bronchodilation results; decrease airway secretions; prevention drugs
Anticholinergics: Tiotropium (Spiriva)
• dry inhalation (not aerosol, administered with no moisture)
• Side effects: Insomnia, dizziness, depression, headache, GI upset, urinary retention, hyperglycemia, blurred vision (contraindicated in patients with narrow-angle glaucomna) and oral ulceration; not a great choice for elderly population
• Adverse effects: Anaphylaxis, angioedema, hyperglycemia, dysrhythmias, paradoxical bronchoconstriction
Anticholinergics: Ipratropium bromide (Atrovent)
• for maintenance therapy; usually a second-line drug; may see used for asthma patients but not as a first choice drug
- Combination of ipratropium bromide with albuterol sulfate (Combivent, DuoNeb)
- Administration: aerosol inhaler
- Side effects: dry mouth, sore throat, headache, GI upset
- Adverse effects: paradoxical bronchoconstriction; worsening of glaucoma and urinary retention (report any change of vision, pain above the eyebrow, or urinary stasis)
Administration Considerations:
• Patients who use a beta-agonist inhalant should administer it 5 minutes before using ipratropium.
• When using the anticholinergic agent in conjunction with an inhaled glucocorticoid (steroid) or cromolyn, the ipratropium bromide should be used 5 minutes before the steroid or cromolyn.

• Inhalation Drug Therapy - Three types:
• Metered-dose inhalers (MDIs)
• Dry-powder inhalers (DPIs)
• Nebulizers
Check before:
• make sure they know the technique of how to use the inhaler; listen to their lung sounds (before & after to know if the treatment worked); vital signs (including temp.) (some medications are contraindicated if the HR is above 120); asses mental status; check hands for tremors; always use a pump to deliver these IV meds
Check after:
• check breathing status (5 minutes); recheck vitals (within 15 minutes); ask about chest pain; check for tremors and restlessness
Patient teaching:
• Correct administration technique for inhalers; check aerosol inhalers by placing them in water (full will sink to the bottom, empty will float)
Life span considerations:
• older adults may be more sensitive to the cardiac and nervous system side effects of bronchodilators; check pulse rates before and after; can be difficult to load the inhaler for older adults who have trouble with fine motor movements
Anti-inflammatory Drugs:
- mainstay therapy for asthma patients
• Corticosteroids, mast cell stabilizers, leukotriene inhibitors
• Principal anti-inflammatory drugs are the glucocorticoids
• Taken daily for long-term control
• Intended responses: Reduced pulmonary secretion, swelling of pulmonary mucous membranes, wheezing; Opened airway lumens; improved airflow; Asthma - PERF within "personal best" range
Glucocorticoids (Anti-inflammatory):
• Mechanism of action = Suppress inflammation
• Decreased synthesis and release of inflammatory mediators
• Decreased infiltration and activity of inflammatory cells
• Decreased edema of the airway mucosa
• Inhaled: budesonide, beclomethasone, fluticasone
• Oral: for acute exacerbations; can suppress growth in children and cause adrenal suppression in adults; Prednisone
• IV: for acute exacerbations; dexamethasone, hydrocortisone, methylprednisolone
• Side effects: local and include bad taste (rinse with water to remove taste), tearing, mouth dryness, and an increased risk for oral infection (thrush); side effects of oral leukotriene inhibitors include headache and abdominal pain
• Adverse effects: inhaled corticosteroids can cause cough severely or cause bronchospasms; when heavily used, they can be absorbed into the bloodstream and cause adrenal gland suppression and oral infections can occur
Mast Cell Stabilizers (Anti-inflammatory):
• Cromolyn sodium
• Mechanism of Action: helps to suppress inflammation; not a rescue drug; thought to help prevent the release of histamine; common with asthma patients
• Route—inhalation: Nebulizer, MDI
• Side effects: usually local, bad taste, dry mouth or throat, nasal congestion
• Adverse effects: paradoxical bronchospasm; angioedema; anaphylaxis
Leukotriene Inhibitors (Anti-inflammatory):
- for prophylactic treatment for asthma patients; usually for kids 12 months and older; not a first-line drug; less effective than the glucocorticoids; reduce the inflammation of chronic bronchitis
• Suppress effects of leukotrienes
• For prevention of inflammatory symptoms of asthma triggered by allergens / environmental contaminants
• Good for exercise induced asthma
• *Not a rescue drug
• Available agents: PO form (pills); Zileuton (Zyflo); Zafirlukast (Accolate); Montelukast (Singulair)
• Side effects: GI upset, dyspepsia, increased upper respiratory infections, headache, abdominal pain
• Adverse effects: neuropsychiatric effects (anxiety, agitation, aggressiveness, depression, hallucinations, vivid dreams, memory impairment); may cause liver impairment (watch for constant fatigue, itchy skin, jaundice) and allergic reactions, including hives and anaphylaxis; extreme psychiatric side effects (depression, psychosis)
Phosphodiesterase-4 (PDE4) Inhibitors:
• roflumilast (Daliresp): only one on the market for end-stage COPD patients; taken every day to help prevent exacerbations in patients with severe COPD
• Not a rescue drug
• Available in tablet form
• Side Effects: weight loss, decreased appetite, GI upset, diarrhea, insomnia
• Adverse Effects: increased SI
Glucocorticoid/LABA Combinations:
• Available combinations: Fluticasone/salmeterol (Advair); Budesonide/formoterol (Symbicort)
• Indicated for long-term maintenance in adults and children (see used for asthma & COPD)
• Not recommended for initial therapy
Drugs for Acute Severe Exacerbations:
• Requires immediate attention: relieve airway obstruction; treat any hypoxia they have; normalize breathing and lung function as quickly as possible
• Initial therapy consists of: make sure they are oxygenated; start IV; give them glucocorticoid; may give them nebulized high-dose SABA; might also give nebulized anticholinergics; monitor everything else that is going on (neuro status, vital signs, protect airway)
Mucolytics:
• Acetylcysteine (Mucomyst): given most commonly as a nebulizer, may also see given in oral form
• Action: usually for COPD patients
• reduce the thickness of mucus, allowing the mucus to more easily move out of the airways; has a very unpleasant odor

• Guaifenesin (Robitussin)
- Action: An expectorant; Loosens bronchial secretions by reducing surface tension of secretions
- Side effects: mild drowsiness (guaifenesin); GI upset (both)
In what area in the lungs does the exchange of oxygen and carbon dioxide take place?
Alveoli
What does the term "bronchoconstriction" refer to?
Constriction of the smooth muscles in the lumen of the lungs
A 24-year-old man who comes to the clinic with reports of wheezing and coughing triggered by cold air is likely experiencing which airway obstruction problem?
Asthma
What types of drugs are used to treat asthma and chronic obstructive pulmonary disease (COPD)? (Select all that apply.)
Anti-inflammatory drugs; Bronchodilators
Which of the following are examples of common bronchodilators? (Select all that apply.)
Salmeterol (Serevent)
Ipratropium (Atrovent)
Albuterol (Ventolin)
Which nursing assessments for patients taking bronchodilators determine improvement of breathing? (Select all that apply.)
Slower respiratory rate
Decreased or absent wheezes
Pulse oximetry value of greater than 95%
Decreased restlessness
What is the intended response of mast cell stabilizers, inhaled corticosteroids, and leukotriene inhibitors?
Decrease the production of mediators that trigger inflammation
Which drug category does montelukast (Singulair) belong to?
Leukotriene inhibitors
What is an important consideration to teach patients to perform daily after taking inhaled corticosteroids?
Rinse the mouth after using the drug to reduce problems.
Acetylcysteine (Mucomyst) is an example of which type of drug?
Mucolytic
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