Roach: Introductory Clinical Pharmacology

Roach: Introductory Clinical Pharmacology

Introduction to Clinical Pharmacology CHAPTER 32 LOWER RESPIRATORY SYSTEM DRUGS Copyright 2018 Wolters Kluwer All Rights Reserved Lower Respiratory System Chronic obstructive pulmonary disease (COPD) is used to describe the disorders of asthma, chronic bronchitis, chronic obstructive bronchitis, and emphysema, or a combination of these conditions. experience dyspnea (difficulty breathing) with

physical exertion, has difficulty inhaling and exhaling, and may have a chronic cough interfere with the exchange of gases in the lung alveoli Copyright 2018 Wolters Kluwer All Rights Reserved Sympathomimetic Bronchodilators: Actions and Uses Actions: open the bronchi and allow more air to enter the lungs, which in turn completely or partially relieves respiratory distress The cholinergic blocking drug ipratropium bromide (Atrovent) is used for bronchospasm associated with COPD, chronic bronchitis, and

emphysema in emergent situations. SABAs such as metaproterenol and albuterol are used as rescue treatment for asthma SABAs such as levalbuterol and terbutaline used for bronchospasm Copyright 2018 Wolters Kluwer All Rights Reserved Sympathomimetic Bronchodilators: Adverse Reactions, Contraindications Adverse CNS effects: tachycardia, palpitations, and/ or cardiac arrhythmias; nervousness; anxiety; hypertension; insomnia Contraindicated: patients with known

hypersensitivity to the drug, cardiac arrhythmias associated with tachycardia, organic brain damage, cerebral arteriosclerosis, and narrow-angle glaucoma; salmeterol is contraindicated during acute bronchospasm Copyright 2018 Wolters Kluwer All Rights Reserved Sympathomimetic Bronchodilators: Precautions LABA and SABA should be Used cautiously in patients with hypertension, cardiac dysfunction, hyperthyroidism, glaucoma, diabetes, prostatic hypertrophy, and history of seizures;

during pregnancy and lactation Copyright 2018 Wolters Kluwer All Rights Reserved Sympathomimetic Bronchodilators: Interactions Interactant drug Adrenergic drugs Monoamine oxidase inhibitors Beta blockers Methyldopa/ tricyclics Oxytocic drugs

Theophylline Effects of interactions Possible additive adrenergic effects Increased risk for severe headache, hypertension, and hypertensive crisis Inhibition of the cardiac, bronchodilating, and vasodilating effects of sympathomimetic Possible hypotension which can be experienced as dizziness when standing up Possible severe hypotension Increased risk for cardiotoxicity

Copyright 2018 Wolters Kluwer All Rights Reserved Xanthine Derivative Bronchodilators: Uses and Adverse Reactions Work by stimulating the CNS to promote bronchodilation Uses: symptomatic relief or prevention of bronchial asthma; reversible bronchospasm associated with chronic bronchitis and emphysema Adverse reactions: CNS reactions: restlessness, nervousness, tachycardia, tremors, headache, palpitations,

increased respiration Other: heartburn that can be alleviated by raising HOB, nausea, vomiting, fever, hyperglycemia, flushing, alopecia Copyright 2018 Wolters Kluwer All Rights Reserved Xanthine Derivative Bronchodilators: Contraindications and Precautions Contraindicated: those with known hypersensitivity, peptic ulcers, seizure disorders, serious uncontrolled arrhythmias Precautions: used cautiously in patients with cardiac disease, hypoxemia, hypertension, congestive heart failure, liver disease, older patients who use alcohol

habitually Aminophylline, dyphylline, oxtriphylline, and theophylline are used cautiously during pregnancy and lactation Copyright 2018 Wolters Kluwer All Rights Reserved Xanthine Derivative Bronchodilators: Interactions Interacts with barbiturates, charcoal, hydantoins, ketoconazole, rifampin, nicotine, adrenergic agents, isoniazid, loop diureticsdecreased theophylline levels such as happens with use of theophylline Interacts with allopurinol, beta blockers, calcium channel blockers, cimetidine, oral contraceptives, corticosteroids,

influenza virus vaccine, macrolide antibiotics, thyroid hormones, isoniazid, loop diureticsincreased theophylline levels Therapeutic theophylline levels range from 10 to 20 mcg/L Monitor theophylline levels for toxicity-signs of toxicity include anorexia, nausea, vomiting, diarrhea, confusion , abdominal cramping, headache, restlessness, insomnia, tachycardia, arrhythmias, or seizures Copyright 2018 Wolters Kluwer All Rights Reserved Antiasthma Drugs: Corticosteroids: Actions, Uses, and Adverse Reactions Actions: given by inhalation and act to decrease the inflammatory process in the airways of the patient with

asthma; increase the sensitivity of the 2 receptors Uses: used in the management and prophylactic treatment of the inflammation associated with chronic asthma or allergic rhinitis and polyps; given before bronchodilator medications; never stop corticosteroid therapy Adverse reactions: Respiratory system reactions: throat (pharyngeal) irritation, hoarseness, URTI, fungal infection of the mouth and throat Other: vertigo, headache Copyright 2018 Wolters Kluwer All Rights Reserved

Corticosteroids: Contraindications, Precautions, and Interactions Contraindicated in patients with hypersensitivity to the corticosteroids, acute bronchospasm, status asthmaticus, or other acute episodes of asthma Precautions: used cautiously in patients with compromised immune systems, glaucoma, kidney disease, liver disease, convulsive disorders, and diabetes; those taking systemic corticosteroids; during pregnancy Interactions: ketoconazole may increase plasma levels of budesonide and fluticasone Copyright 2018 Wolters Kluwer All Rights Reserved

Leukotriene Receptor Antagonists and Leukotriene Formation Inhibitors: Actions, Uses Actions: Zileuton acts by decreasing the formation of leukotrienes Montelukast and zafirlukast inhibit leukotriene receptor sites in the respiratory tract Uses: Zileuton and montelukast are used in the prophylaxis and treatment of chronic asthma in adults and children older than 12 years Route of administration for this category will be orally or subcutaneously Copyright 2018 Wolters Kluwer All Rights Reserved

Leukotriene Receptor Antagonists and Leukotriene Formation Inhibitors: Adverse Reactions #1 Zafirlukast: CNS reactions include headache, influenza-like symptoms Montelukast: CNS reactions include headache and dizziness Copyright 2018 Wolters Kluwer All Rights Reserved Leukotriene Receptor Antagonists and Leukotriene Formation Inhibitors: Adverse Reactions #2 Montelukast (cont.) gastrointestinal reactions include dyspepsia and abdominal

pain respiratory reactions include flu-like symptoms and cough Zileuton headache; GI system reactions, nausea, abdominal pain, may cause liver damage which may present with the following symptoms: upper right quadrant pain, nausea, fatigue, lethargy, pruritus, and jaundice Copyright 2018 Wolters Kluwer All Rights Reserved Leukotriene Receptor Antagonists and Leukotriene Formation Inhibitors: Contraindications and Precautions Contraindicated in patients with known hypersensitivity, bronchospasm in acute asthma attacks, liver disease (zileuton)

Precautions: used cautiously in pregnancy and lactation Copyright 2018 Wolters Kluwer All Rights Reserved Leukotriene Receptor Antagonists and Leukotriene Formation Inhibitors: Interactions Zafirlukast interacts with aspirinincreased plasma levels of zafirlukast; warfarinincreased anticoagulant effect; theophylline, erythromycindecreased level of zafirlukast Zileuton interacts with theophyllineincreased serum theophylline levels; warfarinincreased prothrombin time (PT)

Copyright 2018 Wolters Kluwer All Rights Reserved Mast Cell Stabilizers: Actions Cromolyn can be administered nebulizer, orally, nasal spray, inhaler-when given orally should be taken 30 minutes before meals and bedtime; oral form comes in ampule, it is opened and poured into glass of water, mixing thoroughly and drink all Actions: thought to stabilize the mast cell membrane, possibly by preventing calcium ions from entering mast cells, thus preventing the release of inflammatory mediators Uses: used in combination with other drugs in the treatment of asthma and allergic disorders, including allergic rhinitis (nasal solution), and to prevent exercise-induced

bronchospasm Copyright 2018 Wolters Kluwer All Rights Reserved Mast Cell Stabilizers: Adverse Reactions, Contraindications, and Precautions Adverse reactions: CNS reactions: nasal or throat irritation when given intranasally or by inhalation, unpleasant taste sensation, cough or wheeze Contraindicated: patients with known hypersensitivity to the drug and during acute attacks of asthma Precautions: used cautiously during pregnancy and lactation and in patients with impaired renal or hepatic function Copyright 2018 Wolters Kluwer All Rights Reserved

Nursing Process: Assessment #1 Preadministration assessment: Take the blood pressure, pulse, and respiratory rate before initiation of therapy with a bronchodilator or antiasthma drug; auscultate lungs sounds; if respirations 10 or less contact physician Note any dyspnea, cough, wheezing, noisy respirations, or use of accessory muscles when breathing; also note and record the general physical condition Patients with chronic asthma: question the patient concerning allergies, frequency of attacks, severity of attacks, factors that cause or relieve attacks, and any antiasthma drugs used currently or taken previously

Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Assessment #2 Ongoing assessment: Assess the respiratory status every 4 hours (or more often if needed) and whenever drug is administered this includes assessing lung sounds and use of accessory muscles; keep record of intake and output, report an imbalance; after administration observe the patient for the effectiveness of the drug Copyright 2018 Wolters Kluwer All Rights Reserved

Nursing Process: Diagnoses Anxiety related to feelings of breathlessness Ineffective Airway Clearance related to bronchospasm Impaired Oral Mucous Membranes related to dryness or irritation Imbalanced Nutrition: Less Than Body Requirements related to decreased appetite caused by nausea, heartburn, or unpleasant taste Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Planning

The expected outcomes for the patient depend on the specific reason for administering the drug but may include: Optimal response to therapy Meeting patients needs related to the management of adverse reactions Understanding of and compliance with the prescribed treatment regimen Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Implementation #1 Promoting an optimal response to therapy: Patients taking sympathomimetics: take great care in

reading the primary health care providers order when preparing these drugs for administration Epinephrine: administer epinephrine subcutaneously for an acute bronchospasm; therapeutic effectswithin 5 minutes after administration, last as long as 4 hours Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Implementation #2 Promoting an optimal response to therapy (cont.) Patients taking sympathomimetics: (cont.) Salmeterol: not administered more frequently than twice daily (morning and evening)

Formoterol fumarate (Foradil Aerolizer): administered only by oral inhalation; dosage12 mcg for every 12 hours Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Implementation #3 Promoting an optimal response to therapy (cont.) Patients taking xanthine derivatives: for acute respiratory symptoms, rapid theophyllinization using one of the xanthine derivatives may be required; monitor the patient for signs of theophylline toxicity; report any serum theophylline levels greater than 20 mg/mL or any symptoms associated with toxicity; when

giving theophylline or aminophylline IV, monitor the patient for hypotension, cardiac arrhythmias, and tachycardia Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Implementation #4 Promoting an optimal response to therapy (cont.) Patients taking leukotriene receptor antagonists and leukotriene formation inhibitors: montelukast is administered once daily in the evening; zafirlukast is administered twice daily 1 hour before meals or 2 hours after meals; zileuton is administered four times daily Patients taking oral or inhalant corticosteroids: administer

bronchodilator first; after several minutes administer corticosteroid inhalant; when administering two inhalations of the same drug, it is advisable to wait at least 1 minute between puffs Parents need to be aware that corticosteroids affect growth rate; nurse will need to monitor child growth Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Implementation #5 Promoting an optimal response to therapy (cont.) Patients taking mast cell stabilizers: mast cell stabilizers, such as cromolyn (Intal), may be added to the patients existing treatment regimen (e.g., bronchodilators); when administered orally, cromolyn is given half hour before

meals and at bedtime Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Implementation #6 Monitoring and managing patient needs: Anxiety: patients who have difficulty breathing and are receiving a sympathomimetic drug may experience extreme anxiety, nervousness, and restlessness, which may be caused by their breathing difficulty or the action of the sympathomimetic drug; reassure patients that the drug being administered will most likely relieve the respiratory distress in a short time; closely monitor blood pressure and pulse; speak and act in a calm manner so as not to increase anxiety or

nervousness Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Implementation #7 Monitoring and managing patient needs (cont.) Altered nutrition: less than body requirements: Patient with nausea should be offered frequent smaller meals rather than three large meals; provide pleasant, relaxed atmosphere for meals; heartburn is minimized if the patient remains in an upright position and sleeps with the head of the bed elevated; have the patient take frequent sips of water, suck on sugarless candy, or chew gum to alleviate unpleasant taste caused by antiasthmatic drugs

Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Implementation #8 Monitoring and managing patient needs (cont.) Impaired oral mucous membranes: instruct the patient to use strict oral hygiene, cleanse the inhaler as directed in the package directions, and use the proper technique when taking an inhalation to decrease incidence of candidiasis and help soothe the throat Ineffective airway clearance: during acute bronchospasm, check the blood pressure, pulse, respiratory rate, and response to the drug every 5 to 15 minutes until condition stabilizes and respiratory distress is relieved

Mast cell aerosols such as cromolyn and inhaled corticosteroids (ICSs) such as fluticasone and budesonide/formoterol have been associated with the development of (Candida albicans) oral thrush Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Implementation #9 Educating the patient and family: Provide a thorough explanation on the use of the aerosol inhalator for administration of bronchodilator; carry rescue inhaler Carefully review any instruction sheets with the patient and provide information about how the unit is assembled, used, and cleaned Teach the patient how to use the peak flow meter and when to notify the primary health care provider ensure they know to stand

upright, lips form a tight seal, exhale forcibly and quickly; do at same time each day To properly use a dry powder inhaler, the client should do the following: prepare the medication for inhalation, place the mouthpiece close to the lips, inhale quickly, hold breath for 10 seconds, not swallow capsules provided, and not place the inhaler in water. With inhalers need to be sure to rinse mouth after each use Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Implementation #10 Educating the patient and family: The Asthma Care Plan utilizes the stop light approach with red, yellow, and green activities to guide the client

in helping to maintain their control of asthma. Factors such as staying in the yellow zone for more than 24 hours and quick-relief medications not working are found in the red zone and necessitate an immediate call to the health care provider to advert a crisis. Clients with chronic stable asthma should monitor for symptoms such as wheezing, coughing, peak flow changes, and triggers that might be making the asthma worse. Copyright 2018 Wolters Kluwer All Rights Reserved Nursing Process: Evaluation The therapeutic effect is achieved, and breathing is easier and more effective

Patient maintains adequate nutrition Oral mucous membranes are intact and integrity is maintained Airway is maintained with effective breathing pattern Anxiety is managed successfully Adverse reactions are identified, reported to the primary health care provider, and managed successfully The patient demonstrates an understanding of the drug regimen and use of the aerosol inhalator Copyright 2018 Wolters Kluwer All Rights Reserved Question #1 Is the following statement true or false? Asthma is a acute lung condition causing spasmodic

constriction of the bronchi and lung inflammation. Many Americans suffer from the ailment and it is one of the most common childhood chronic conditions. Copyright 2018 Wolters Kluwer All Rights Reserved Answer to Question #1 False Asthma is a chronic lung condition causing spasmodic constriction of the bronchi and lung inflammation. Many Americans suffer from the ailment and it is one of the most common childhood chronic conditions. Copyright 2018 Wolters Kluwer All Rights Reserved

Question #2 Is the following statement true or false? Bronchodilators are used for patients with COPD who experience difficulty breathing (dyspnea) and the interference of gas exchange at the alveoli level in the lungs. Copyright 2018 Wolters Kluwer All Rights Reserved Answer to Question #2 True Bronchodilators are used for patients with COPD who experience difficulty breathing (dyspnea) and the

interference of gas exchange at the alveoli level in the lungs. Copyright 2018 Wolters Kluwer All Rights Reserved Question #3 Is the following statement true or false? Antiasthma drugs are used for both long-term management and short-term breathing relief. Copyright 2018 Wolters Kluwer All Rights Reserved Answer to Question #3 True

Antiasthma drugs are used for both long-term management and short-term breathing relief. Guidelines for medication use are called the Step Method. Inhaled corticosteroids reduce inflammation, while bronchodilators relieve bronchospasm. Providers define parameters and help the patient to make an asthma action plan to help the patient in self-management of the condition. Copyright 2018 Wolters Kluwer All Rights Reserved

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