Ppt chapter 35

Chapter 35
Drugs Affecting the Lower
Respiratory System
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Physiology
• The lower respiratory tract is virtually sterile because of the
various defense mechanisms in the upper respiratory system.
• Protective mechanisms
– All the tubes in the lower airway contain goblet cells,
which secrete mucus to entrap any particles.
– Microorganisms and other foreign bodies are removed
from the air by tiny hair-like structures called cilia.
• Gas exchange, perfusion, and respiration
– Lung tissue receives its blood supply from the bronchial
artery, which branches directly off the thoracic aorta.
• Ventilation
– The act of breathing is controlled by the central nervous
system (CNS).

Lower Respiratory Tract

Pathophysiology
• Acute bronchitis is caused most frequently by viruses.
• Asthma is a disorder characterized by recurrent
episodes of bronchospasm, bronchial muscle spasm
that leads to narrowed or obstructed airways.
• Chronic airway limitation (CAL) is an umbrella term
that describes gradually progressive, degenerative
diseases, such as chronic bronchitis, emphysema, or
repeated, severe asthma attacks.
• Chronic bronchitis is long-standing, largely irreversible
inflammation of the bronchial tree.

Pathophysiology (cont.)
• Emphysema is an abnormal distention of the lungs with
air characterized by loss or degeneration of elastic tissue,
disappearance of capillary walls, and breakdown of the
alveolar walls.
• Pneumonia is an inflammation of the lungs. It can be
caused by bacterial or viral invasion of the tissue or by
aspiration of foreign substances into the lower respiratory
tract.
• Cystic fibrosis is a hereditary disease that affects the
functioning of the body’s exocrine glands: the mucus-secreting
and sweat glands.

Mucolytic Drugs
• Mucolytics break down mucus.
• The drugs can be administered by a nebulizer or by direct
instillation into the trachea.
• Mucolytics usually are reserved for patients who have
major difficulty mobilizing and coughing up secretions.
• Prototype drug: acetylcysteine (Mucomyst)

Acetylcysteine: Core Drug Knowledge
• Pharmacotherapeutics
– Used to liquefy the thick, tenacious secretions.
• Pharmacokinetics
– Administered: inhalation. Onset: 1 minute.
• Pharmacodynamics
– It splits disulfide bonds that are responsible for
holding the mucous material together.

Acetylcysteine: Core Drug Knowledge
(cont.)
• Contraindications and precautions
– Hypersensitive
• Adverse effects
– Bronchospasm, bronchoconstriction, chest tightness,
a burning feeling in the upper airway, and rhinorrhea
• Drug interactions
– No important drug interactions have been reported
for acetylcysteine .

Acetylcysteine: Core Patient Variables
• Health status
– Perform a physical examination to establish
baselines.
• Life span and gender
– Determine pregnancy and lactation status.
• Environment
– Usually given in a supervised environment

Acetylcysteine: Nursing Diagnoses and
Outcomes
• Ineffective Airway Clearance related to drug effect or
bronchospasm
– Desired outcome: The patient’s airway will be
maintained without increased difficulty breathing.
• Disturbed Sensory Perception, Olfactory, related to odor
of drug and route of administration
– Desired outcome: The patient will remain
comfortable and able to tolerate drug therapy.

Acetylcysteine: Nursing Diagnoses and
Outcomes (cont.)
• Imbalanced Nutrition: Less than Body Requirements,
related to nausea and vomiting.
– Desired outcome: The patient will maintain
nutritional balance throughout therapy.
• Risk for Injury related to anaphylactoid reaction
– Desired outcome: Potential anaphylactoid reactions
will be recognized and treated appropriately.

Acetylcysteine: Planning and
Interventions
• Maximizing therapeutic effects
– Administer an inhaled beta-agonist before
administering acetylcysteine.
• Minimizing adverse effects
– Inform the patient that nebulization may produce an
initially disagreeable odor, but that this odor is
transient.

Acetylcysteine: Teaching, Assessment,
and Evaluation
• Patient and family education
– Explain the rationale for receiving acetylcysteine.
– Inform patients that they must not take this drug
without the assistance of a respiratory therapist.
– Teach patients and their family members all aspects
of pulmonary hygiene.
• Ongoing assessment and evaluation
– For the patient receiving acetylcysteine for its
mucolytic effects, assess the patient for proper
techniques of pulmonary hygiene and respiratory
status.

Question
• Acetylcysteine is administered by
– A. Inhalation
– B. SC
– C. Oral
– D. IV

Answer
• A. Inhalation
• Rationale: Acetylcysteine is delivered directly to the
respiratory system by nebulizer (inhalation) or direct
instillation.

Bronchodilators
• Bronchodilators are drugs used to facilitate respiration by
dilating the airways.
• Bronchodilators may be administered orally, parenterally,
or by inhalation.
• Inhalation is the most frequent method using metered-dose
inhalers (MDIs) or dry-powder inhalers (DPIs).
• Beta-agonists (sympathomimetics)
– One of the actions of beta stimulation in the
sympathetic nervous system is dilation of the bronchi
and increased rate and depth of respiration.
• Prototype drug: albuterol (Proventil, Ventolin)

Albuterol: Core Drug Knowledge
– Bronchodilator in managing CAL and asthma
– Administered: inhalation. Excreted: urine and feces.
Onset: 5 to 15 minutes.
– It selectively stimulates receptors of the smooth
muscle in the lungs, the uterus, and the vasculature
that supplies the skeletal muscle.

Albuterol: Core Drug Knowledge (cont.)
– Hypersensitivity
• Adverse effects
– Tachycardia, palpitations, anxiety, tremors,
headache, insomnia, muscle cramps, and
gastrointestinal (GI) symptoms
– Other sympathomimetic agents, beta-adrenergic
blocking agents, digoxin, antidepressants, and
potassium-losing diuretics

Albuterol: Core Patient Variables
• Health status
– Assess medical condition and contraindications to
therapy.
– Pregnancy Category C drug
• Lifestyle, diet, and habits
– Assess caffeine intake.
• Environment
– Frequently given at home

Albuterol: Nursing Diagnoses and
Outcomes
• Anxiety related to sympathomimetic effects of albuterol
administration
– Desired outcome: The patient will engage in
interventions that decrease anxiety.
• Ineffective Tissue Perfusion: Cardiopulmonary related to
rebound bronchoconstriction caused by overuse of
albuterol
– Desired outcome: The patient will use albuterol as
prescribed by the health care provider and contact
that person if symptoms do not abate.

Albuterol: Planning and Interventions
– To obtain the correct dose of albuterol, prime the
device.
– The patient should be encouraged to contact the
health care provider to obtain adjunctive medications
if symptoms persist, rather than increase the
frequency of albuterol use.

Albuterol: Teaching, Assessment, and
Evaluation
– Teach patients that inhaled albuterol is called a
“rescue drug.”
– Teach patients how to use an MDI.
– Explain the importance of limiting caffeine intake.
– Evaluate for the symptoms of asthma or CAL in
patients using albuterol.

Question
• Albuterol is given for acute exacerbation of CAL or
asthma.
– A. True
– B. False

Answer
• A. True
• Rationale: Albuterol is considered a “rescue inhaler”
and is used for acute exacerbations of lung disease.

Respiratory Anticholinergic Agents
• Inhaled anticholinergic drugs are considered first-line
treatment for patients with CAL.
• Anticholinergic agents diminish the effect of
acetylcholine.
• In the respiratory system, use of inhaled anticholinergic
drugs stops the bronchoconstriction.
• Prototype drug: ipratropium bromide (Atrovent)

Ipratropium Bromide: Core Drug
Knowledge
– Used for maintenance treatment of bronchospasm
– Administered: inhalation. Onset: 15 to 30 minutes.
– Antagonizes the action of acetylcholine by blocking
muscarinic cholinergic receptors

Ipratropium Bromide: Core Drug
Knowledge (cont.)
– Sensitivity to ipratropium and atropine
• Adverse effects
– Paradoxic acute bronchospasm, cough, hoarseness,
throat irritation, or dysgeusia
– No serious drug–drug interactions are associated
with ipratropium

Ipratropium Bromide: Core Patient
Variables
• Health status
– Assess for medical complication to therapy.
– Pregnancy Category B drug
– Determine if the patient smokes.
• Environment
– Administered at home

Ipratropium Bromide: Nursing Diagnoses
and Outcomes
• Risk for Injury (bronchospasm) related to use of new
canister of ipratropium
– Desired outcome: The patient will “test-spray” a
new canister three times before inhaling the
medication.
• Risk for Injury (anaphylactoid reactions) related to
allergies to soybeans, legumes, or soya lecithin.
– Desired outcome: The patient will review past
allergic responses to assess whether any of the
causative foods may have been responsible.

Ipratropium Bromide: Planning and
Interventions
– Explain the importance of taking ipratropium daily,
despite the absence of symptoms.
– Explain the importance of using the MDI as
prescribed to avoid systemic absorption that leads to
an increased risk of adverse effects.

Ipratropium Bromide: Teaching,
Assessment, and Evaluation
– Advise patients that ipratropium is used
prophylactically.
– Remind patients that overuse of ipratropium may
induce adverse effects.
– Assess the patient’s need for beta-agonist drugs in
addition to ipratropium.

Question
• Patients with hypersensitivity to ________ cannot use
ipratropium bromide.
– A. Dairy
– B. Eggs
– C. Wheat
– D. Legumes

Answer
– D. Legumes
– Rationale: A major contraindication for taking
ipratropium bromide is a hypersensitivity to legumes,
such as soybeans or peanuts.

Xanthine Derivatives
• The xanthine derivatives, including theophylline,
aminophylline, diphylline, and caffeine, come from a
variety of naturally occurring sources.
• They are excellent bronchodilators but do not work as
rapidly as beta-adrenergic agonist drugs.
• Prototype drug: theophylline (Elixophyllin, Theo24,
Uniphyl)

Theophylline: Core Drug Knowledge
– Indicated for the symptomatic relief or prevention of
bronchial asthma and reversal of bronchospasm
– Administered: oral or IV. Metabolism: liver. Excreted:
kidneys. Peak: 2 hours.
– It is believed that bronchodilation is caused by
inhibition of phosphodiesterase.

Theophylline: Core Drug Knowledge
(cont.)
– Hypersensitivity, status asthmaticus, or peptic ulcer
• Adverse effects
– Adverse effects related to theophylline use are
related directly to serum levels of the drug.
– Multiple drug interactions

Theophylline: Core Patient Variables
• Health status
– Assess for contraindications to therapy.
– Assess pregnancy and lactation status.
– Assess if the patient smokes.
• Environment
– IV formulation given in acute care setting

Theophylline: Nursing Diagnoses and
Outcomes
• Disturbed Sensory Perception: Kinesthetic related to CNS
effects of irritability, insomnia, and dizziness
– Desired outcome: The patient will be protected from
injury caused by CNS effects, such as dizziness and loss of
balance.
• Ineffective Tissue Perfusion: Cardiopulmonary related to
cardiac effects of the drug
– Desired outcome: Adverse effects will be limited by
proper administration and monitoring of drug serum
levels.
• Risk for Injury related to headache, GI effects, and CNS effects
– Desired outcome: The patient will develop strategies to
be able to tolerate the drug and remain injury-free during
drug therapy.

Theophylline: Planning and Interventions
– In the hospital setting, administer theophylline at a
rate of 20 mg/minute.
– Monitor serum theophylline levels carefully and
discuss dosage adjustment.
– Administer immediate-release preparations with a
meal to decrease GI distress.

Theophylline: Teaching, Assessment, and
Evaluation
– Explain that theophylline will help make breathing
easier.
– Explain the importance of taking theophylline exactly
as prescribed.
– Monitor the patient taking theophylline for potential
adverse CNS and cardiovascular effects.

Question
• Theophylline serum levels should be _______ to prevent
adverse reactions.
– A. Less than 10 mcg/mL
– B. Less than 20 mcg/mL
– C. Less than 40 mcg/mL
– D. Less than 60 mcg/mL

Answer
• B. Less than 20 mcg/mL
• Rationale: Adverse effects related to theophylline use
are related directly to serum levels of the drug. At
serum levels less than 20 mcg/mL, adverse effects
are uncommon.

Anti-Inflammatory Agents
• In addition to bronchodilators, anti-inflammatory agents
are used to manage respiratory disorders, especially
asthma.
• Inhaled glucocorticoid steroids
– Glucocorticoid steroids are the most effective anti-inflammatory
drugs available for managing
respiratory disorders.
– They can be given orally, parenterally, or by
inhalation.
– Inhaled corticosteroid (ICS) agents have become
first-line treatment for persistent asthma.
• Prototype drug: flunisolide (AeroBid)

Flunisolide: Core Drug Knowledge
– Used to prevent bronchospasm
– Administered: parenteral, oral, or by inhalation.
– Inhibit the production of leukotrienes and
prostaglandins through interference with arachidonic
acid metabolism.

Flunisolide: Core Drug Knowledge (cont.)
– Active systemic fungal infection
• Adverse effects
– Sore throat, hoarseness, coughing, dry mouth, and
pharyngeal and laryngeal fungal infections
– No important drug–drug interactions occur with
flunisolide.

Flunisolide: Core Patient Variables
• Health status
– Assess signs of active lung infection.
– Pregnancy Category C drug
– Caution about smoking.
• Environment
– Given in home care setting

Flunisolide: Nursing Diagnoses and
Outcomes
• Impaired Verbal Communication related to dysphonia and
cough
– Desired outcome: The patient will report symptoms
to the health care provider.
• Risk for Infection related to immunosuppression
– Desired outcome: The patient will remain free of
infection throughout therapy.

Flunisolide: Planning and Interventions
– Instruct the patient to take flunisolide every day,
regardless of how well the patient feels.
– Using a beta-2 agonist before flunisolide dilates the
bronchial tree
– Spacers may help alleviate dysphonia by filtering
larger aerosol particles.

Flunisolide: Teaching, Assessment, and
Evaluation
– Patient education is important for inhaled steroid
therapy.
– Importance of daily use, regardless of the absence of
symptoms
– Assess for a decreased incidence of acute asthma
attacks.

Question
• Patients using flunisolide are at a high risk for developing
– A. Oral bacterial infection
– B. Oral viral infection
– C. Oral fungal infection

Answer
• C. Oral fungal infection
• Rationale: Oropharyngeal Candida albicans infection
is a common adverse effect associated with daily use
of ICS.

Mast Cell Stabilizers
• Vasoactive substances, such as histamine, serotonin,
bradykinin, and leukotrienes, are located within the mast
cell.
• When the mast cell ruptures, these substances cause an
inflammatory response, such as bronchial constriction,
which accounts for the symptoms of an acute asthma
attack.
• Prototype drug: cromolyn sodium

Cromolyn Sodium: Core Drug Knowledge
– Prophylactic agent in treating mild-to-moderate
asthma
– Administered: inhalation or oral. Distribution: lungs.
Excreted: feces.
– Works at the surface of the mast cell to inhibit mast
cell rupture and degranulation after contact with an
antigen

Cromolyn Sodium: Core Drug Knowledge
(cont.)
• Adverse effects
– Bronchospasm, throat irritation, and cough
– No clinically important drug interactions are known
with cromolyn sodium.

Cromolyn Sodium: Core Patient Variables
• Health status
– Evaluate for previous reaction to the drug.
– Monitor for lactose intolerance.
• Environment
– Assess the environment where the drug will be given.

Cromolyn Sodium: Nursing Diagnoses and
Outcomes
• Imbalanced Nutrition: Less than Body Requirements
related to nausea and vomiting, bloating, abdominal
cramps, and flatulence
– Desired outcome: The patient will maintain body
weight throughout therapy.
• Ineffective Breathing Pattern related to bronchospasm
and cough
– Desired outcome: The patient will have a patent
airway throughout therapy.

Cromolyn Sodium: Planning and
Interventions
– Cromolyn sodium is used for long-term management
of respiratory disorders.
– Caution patients who have a known intolerance to
lactose.

Cromolyn Sodium: Teaching, Assessment,
and Evaluation
– Emphasize that cromolyn sodium is not useful for
managing acute symptoms.
– Teach the patient how to use a peak flow meter to
monitor his or her personal respiratory status.
– Evaluate the effectiveness of cromolyn sodium,
demonstrated by a decrease in the frequency and
severity of symptoms.

Question
• The patient has been prescribed cromolyn sodium for
exercise-induced asthma. What would you teach about
administration of this medication?
– A. Take medication daily
– B. Only take medication if you are having symptoms
– C. Take during exercise to prevent symptoms
– D. Take 15 to 20 minutes before exercise

Answer
• D. Take 15 to 20 minutes before exercise
• Rationale: Advise patients who experience exercise-induced
bronchospasm to take cromolyn sodium 15
to 20 minutes before exercise.

Leukotriene Receptor Antagonists
• Leukotrienes are inflammatory mediators that are
powerful bronchoconstrictors and vasodilators.
• Leukotrienes have been identified as important mediators
in the pathology and symptomatology of asthma
• Result in airway hyperreactivity, bronchoconstriction, and
hypersecretion
• Prototype drug: zafirlukast (Accolate)

Zafirlukast: Core Drug Knowledge
– Prophylaxis or treatment of chronic asthma
– Administered: oral. Metabolism: liver. Excreted:
urine and feces.
– Blocks receptors for the leukotrienes bound to the
amino acid cysteine

Zafirlukast: Core Drug Knowledge (cont.)
• Adverse effects
– Headache, gastritis, pharyngitis, and rhinitis
– Theophylline, warfarin, aspirin, erythromycin, and
drugs metabolized through the P-450 CYP2C9

Zafirlukast: Core Patient Variables
• Health status
– Assess medical status and liver function.
– Take medication on an empty stomach.
• Environment
– Generally given at home

Zafirlukast: Nursing Diagnoses and
Outcomes
• Risk for Injury (poisoning) related to interaction between
drugs metabolized by the P-450 enzyme system
– Desired outcome: The patient will adhere to dosage
adjustment of medications, undergo serial laboratory
testing, and report adverse effects immediately to
the health care provider.
• Diarrhea related to drug therapy
– Desired outcome: The patient will remain well
hydrated throughout therapy.
• Acute Pain related to drug therapy
– Desired outcome: The patient will take nonnarcotic
analgesics if headache occurs.

Zafirlukast: Planning and Interventions
– Ensure that the patient takes zafirlukast twice daily
despite the absence of symptoms.
– Ensure that the patient takes the medication only as
prescribed.

Zafirlukast: Teaching, Assessment, and
Evaluation
– Explain that zafirlukast is used in maintenance
therapy.
– Encourage patients to take nonnarcotic analgesics if
headache occurs.
– Assess whether the patient needs beta-agonist drugs
in addition to zafirlukast.

Question
• Zafirlukast is used for
– A. Prophylaxis
– B. Acute attack
– C. Infection
– D. All of the above

Answer
• A. Prophylaxis
• Rationale: Zafirlukast is used as prophylaxis or for
treating chronic asthma.

Ppt chapter 35

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