The document discusses the respiratory system and drugs used to treat respiratory diseases like asthma. It provides facts about the respiratory system and describes different types of asthma. It then summarizes various drug classes used to treat asthma, including beta-2 agonists, corticosteroids, leukotriene receptor antagonists, mast cell stabilizers, and monoclonal antibody therapy. The drugs discussed provide bronchodilation and reduce inflammation in the respiratory tract.

1. RESPIRATORY SYSTEM

2. INTERESTING FACTS ABOUT RESPIRATORY
SYSTEM

3. The surface area of the lungs is roughly the same
size as a tennis court.

4. The capillaries in the lungs would extend 1,600
kilometres if placed end to end.

5. A person at rest usually breathes between 12 and
15 times a minute.

6. The breathing rate is faster in children and
women than in men.

8. PULMONARY
PHARMACOLOGY
Dr. V.SATHYANARAYANAN M.D
PROFESSOR OF PHARMACOLOGY

9. PULMONARY
PHARMACOLOGY
 Effects of drugs on the airways and the
therapy of airway obstruction.
 Pharmacotherapy of Asthma , COPD ( most
common chronic diseases )
 Pharmacotherapy of cough ( most common
Respiratory symptom )
 O2, respiratory stimulants
 Pulmonary hypertension

10. DRUGS FOR BRONCHIAL
ASTHMA

12. BRONCHIAL ASTHMA
 Hyper responsiveness of tracheo-bronchial
smooth muscle
 resulting in narrowing of bronchial tree
 Wheezing attacks
 polygenic
 Primarily inflammatory condition

19. Mediators in Asthma
 Mediators released are > 100 in number
 histamine, TNFa - immediate
 Prostaglandins, leukotrienes, PAF –
within min
 Interleukins, TNFa – /over hrs

22. Symptoms of Asthma
• Wheezing
• Cough, especially at night
• Chest tightness
• Shortness of breath
• Characteristically occur or worsen at night,
with exercise, with viral infections, or with
exposure to dust, animals, or smoke

27. TYPES
 EXTRINSIC ASTHMA – Commonest,
episodic, allergens involved. Atopic ,
immediate (type I) hypersensitivity reaction is
invlved
 INTRINSIC ASTHMA – without allergens,
Perennial
 EXERCISE INDUCED ASTHMA – asthma
following exercise, cold air, airway drying
 ASTHMA ASSOCIATED WITH COPD

30. APPROACHES TO
TREATMENT
 PREVENTION OF EXPOSURE TO
ALLERGEN(S)
Avoid Grasses, Pollens, Animals
HISTORY
RAST test
Intradermal skin prick test
 NEUTRALISATION OF IgE - omalizumab

32. APPROACHES TO
TREATMENT
 REDUCTION OF BRONCHIAL
INFLAMMATION & HYPERREACTIVITY
 Glucocorticoids
 Sodium cromoglicate
 Nedocromil sodium
 Ketotifen
 PAF antagonists

34. APPROACHES TO
TREATMENT
 DILATATION OF NARROWED BRONCHI
 Physiological antagonism of bronchial muscle
contraction
 BETA2 receptor agonists
 Methyl xanthines
 Antimuscarinic bronchodilators
 Leukotriene receptor antagonists

36. BETA2 AGONISTS
 Salbutamol (Albuterol )
 Terbutaline
 Bambuterol
 Salmeterol
 Formeterol

37. SALBUTAMOL
 Beta2 stimulation  inc.cyclic AMP
relaxation, prevent bronchoconstriction,
decreases mediator release
 Fastest acting , within 5 min, lasts for 2-4 hrs
 Relieves symptoms
 Used to abort acute attacks of asthma
 ADR – tremors, palpitation, restlessness, ankle
edema, hypokalemia, hypoxemia
 Orally in severe asthma
 Regular use – down regulation of receptors

43. TERBUTALINE
 Similar to salbutamol
 Used only for symptomatic relief

44. BAMBUTEROL
 Prodrug
 Hydrolysed by pseudocholinesterase into
active drug
 Release over 24 hrs
 Indicated in chronic bronchial asthma
 Single evening dose 10 -20 mg

46. SALMETEROL
 Long acting beta2 agonist
 Slow onset of action
 Used by inhalation
 Twice a day schedule
 For maintenance therapy and nocturnal
asthma

47. FORMOTEROL
 Long acting beta2 agonist
 Acts for 12 hrs when inhaled
 Faster than salmeterol.
 Used as a Regular twice a day schedule for
round the clock bronchodilatation.

48. FUTURE DEVELOPEMENTS
 Beta2 agonists continue to be 1st choice –
effective in all, few or no side effects in low
doses
 LABA – very useful control of asthma, COPD
 LABA only for patients receiving ICS
 Once daily drugs – indacaterol, carmoterol –
under trials

49. OTHER BETA AGONISTS
 Adrenaline, ephedrine, isoprenaline
 Less safe – cause cardiac arrhythmias

51. THEOPHYLLINE
 Methyl Xanthine
 Inhibit phosphodiesterase, release Ca, block
adenosine receptors, increases IL -10 release
 CNS stimulant, increases HR, Diuretic,
increases acid secretion, dilate bronchi
 Also used in COPD (as effective on smaller
airways and has anti-inflammatory action)
 Use has declined because of safety

55. THEOPHYLLINE - ADR
 Insomnia, nervousness, flushing
 Tremors
 At high therapeutic doses  nausea, diarrhea
 IN OVERDOSE –
 Vomiting, Palpitation, Arrhythmias,
hypotension, hypokalemia, seizures
 Tt – potassium replacement , diazepam

63. THEOPHYLLINE – DRUG
INTERACTIONS
 Microsomal enzyme inhibitors ( ciprofloxacin,
erythromycin ) increases toxicity
 Enzyme inducers decrease levels
 Theophylline enhances the effects of
furosemide, sympathomimetics,
hypoglycemics
 PK – elimination changes 1st order to 0 order
 Has low therapeutic index – need monitoring

65. USES
 Inexpensive  cost friendly  wider use in
India
 Low efficacy
 Frequent side effects
 Use sustained release preparations, S.R OD
drugs
 Minority of patients still benefited
 Bronchial asthma – severe, nocturnal asthma,
steroid sparing action
 COPD  more severe cases
 Apnoea in premature infant

66. I.V. AMINOPHYLLINE
 ACUTE SEVERE ASTHMA – 6mg/kg
 COPD--Less effective, high incidence of ADR

67. FUTURE DEVELOPMENTS
 Usage declining
 Oral theophylline  difficult asthma
 Plasma levels of 5-15 mg/L are recommended
 Low dose T + ICS combination
 Reverses corticosteroid resistance in COPD
 Low dose T  Anti inflammatory effect 
Prevents progression COPD

69. ANTIMUSCARINIC
BRONCHODILATORS
 Ipratropium bromide, oxitropium, tiotropium
( effects last for up to 24 hrs )
 Block M3 receptors
 Inhaled  less systemic effects
 Slower response
 Better suited for regular prophylactic use
 Less effective than salbutamol
 Useful in COPD, refractory asthma, acute
severe asthma

72. CLINICAL USES
 In asthma Not controlled by LABA
 Elderly with fixed narrowing
 COPD- bronchodilators of choice, as effective
as BA or even superior
 Less systemic side effects, bitter taste,
glaucoma (nebulised form)
 Ipratropium bromide –MDI
 Combivent – in COPD
 Tiotropium – long acting  od dose as a DPI

73. NOVEL BRONCHODILATORS
 Magnesium sulfate  acute severe asthma
 K+ channel openers – (cromakalim)- CVS side
effects
 Atrial Natriuretic Peptides – different
mechanism –useful in acute severe asthma
not responding
 Vasoactive Intestinal Poly Peptide analogs 
vasodilator side effects
More studies are needed before
routine use

75. CORTICOSTEROIDS
 Suppress inflammatory response
 Mainstay ( 1st line therapy ) of asthma
treatment
 Slowly and Gradually reduce bronchial hyper
reactivity
 Do not dilate bronchi
 Afford complete & sustained relief
 Decrease disease progression
 Inhaled steroids – only few ADR
 Long term systemic therapy – more ADR

76. CORTICOSTEROIDS
 Prednisolone – given orally 30-40mg/day single
dose in the morning
INHALED STEROIDS
 Beclomethasone dipropionate – given BD
 Budesonide -Better than beclomethasone
 Fluticasone propionate – less systemic effects,
BD
 Ciclesonide – 80-160 micg OD, novel approach
drug with oral BA<1%, extensively bound to
plasma proteins

77. Effects of Inhaled
Corticosteroids on
Inflammation
Laitinen et al. J Allergy Clin Immunol 1992;90:32-
42
Compromis
ed
Epithelium
TThhiicckkeenneedd BBMM
IInnffllaammmmaattoorryy CCeellllss Intact
Epithelium
¯
Inflammatory
Cells

79. INHALED STEROIDS
 High topical activity
 Indicated if beta2 agonist required daily
 ADR – hoarseness of voice, dysphonia,
oropharyngeal candidiasis, sore throat
 Safe during pregnancy
 > 600 micrograms/day  systemic effects
 C/I - Infection

84. COMBINATION INHALERS
 A LABA + CORTICOSTEROID –
(salmeterol /fluticasone, formoterol/budesonide
 Has complementary synergistic actions
 More convenient
 Allows beneficial molecular interaction

85. FUTURE DEVELOPMENTS
 Early treatment with ICS in adults and children
may improve lung function greatly
 For persistent asthma and chronic symptoms
 Soft steroids ( butixocort ) proved
disappointing
 Dissociated steroids ( selective ) difficult
 Corticosteroid resistance – major barrier

87. MAST CELL STABILIZERS
 Sodium cromoglycate, nedocromil
 Alternative to inhaled steroids
 Inhibit degranulation of mast cells – prevent
release of mediators, inhibit other inflammatory
cells, local axon reflexes
 Given by inhalation
 Prevent bronchospasm induced by allergens,
irritants, cold air, exercise
 Other Uses – allergic rhinitis, conjunctivitis
 ADR- mild, like cough, throat irritation
 Usage has declined

95. KETOTIFEN
 H1Antihistamine
 Like cromoglycate
 Orally given
 ADR – Sedation, dry mouth, weight gain
 1-2 mg BD
 Also used in other allergic disorders

100. LEUKOTRIENE RECEPTOR
ANTAGONISTS  Montelucast (OD) , zafirlucast (BD)
 Prevents the bronchoconstrictor effects of LTC4,
D4, E4
 overall efficacy lower than inhaled steroids
 Used in prophylaxis alternate to steroids
 Reduces the dose of steroids
 More acceptable in children
 Effective in aspirin induced asthma
 No role in COPD
 Very safe, few side effects- headache, rash
 rarely cause churg- strauss syndrome
 2nd – 3rd line role

101. Cysteinyl-
LT receptor
antagonists
-
zafirlukast
-
montelukast
5-LO
inhibitors
- zileuton

106. ZILUTON
 5 Lipoxygenase inhibitor
 Prevent all LT induced responses
 Efficacy similar to LT antagonists
 Limitations – short duration, hepatotoxicity

108. FUTURE DEVELOPMENTS
 Tablet form  increased compliance
 Od dose
 Children
 Less use in future
 Role in some patients

109. IMMUNOMODULATORY
THERAPIES
 Immunosuppression – less effective, more
side effects
 ANTI – IgE therapy

110. OMALIZUMAB
 A monoclonal antibody against IgE
 Binds to IgE  form a complex make IgE not
bind to IgE receptors on mast cells and basophils
 inhibition of allergic response
 Given S.C once in 2-4 weeks
 Reduces requirement of steroids
 ADR – Well tolerated, pain at the site of inj., allergy
 Caution – a very small% developed cancers
 Uses – resistant asthma with raised IgE levels who
require frequent hospitalisation
 EXPENSIVE

112. STATUS ASTHMATICUS
 Also known as refractory asthma , acute
severe asthma
 May be life threatening
 A medical emergency
 URI is mostly the precipitant
 Other triggers – drugs, stress, allergens,
abrupt withdrawal of steroids after prolonged
use

114. STATUS ASTHMATICUS
 Nebulized salbutamol (2.5-5 mg ) over 3 min, rpt in
15 min + ipratropium (0.5 mg ) intermittent inhalation
 Intermittent high flow humidified Oxygen inhalation by
mask
 Hydrocortisone hemisuccinate 100 mg i.v stat
followed by 100 – 200 mg 4-8 hourly infusion
 Salbutamol/Terbutaline 0.4 mg i.m/s.c may be added
 Antibiotics
 i.v fluids + sodium bicarbonate infusion
 Intubation and mechanical ventilation, if needed
 Aminophylline i.v use is restricted to resistant cases
 NO SEDATION

120. DRUG TREATMENT OF
ASTHMA
 Varies with the severity and the type
 Monitored by measuring PEFR, FEV1
 Severe attacks  measure ABG

121. SEASONAL ASTHMA
 inhaled cromoglycate or low dose
inhal.steroids
 Regularly 3-4 weeks before, continue till 3-4
weeks after season is over
 Individual episodes – short acting inhal. Beta2
agonist

124. CHOICE OF TREATMENT – MILD
EPISODIC ASTHMA
 Symptoms < once daily, normal between
attacks
 Inhaled beta2 agonist at onset of episode –
(Step1)
 Regular Prophylaxis not required

125. MILD CHRONIC ASTHMA
WITH OCCASIONAL
EXACERBATIONS
 Symptoms once daily
 Regular Low dose inhal. Steroids or
cromoglicate – (step2)
 Episode treatment with short acting inhal.
Beta2 agonist

127. MODERATE ASTHMA with
frequent exacerbations
 Attacks affect activity
 Occur > 1/day
 Increasing doses of Inhal. Steroids upto 800
micrograms/day + inhal. Long acting beta2
agonist – (Step3)
 Or LT antagonist for steroids
 Theophylline may be used as an alternative

128. SEVERE ASTHMA
 Continuous symptoms, activity limitation, frequent
attacks requiring hospitalisation
 Regular high dose inhaled steroids ( 800 – 2000
micrograms/ day ) with spacer + Inhaled salmeterol
BD
 Additional tt with one or more of a Leukotriene
antagonist/ Oral theophylline S.R/ oral beta2
agonist/ inhaled ipratropium –( Step4)
 Not controlled or needing frequent hospitalisation
 oral steroids – (Step5 )(periodically withdraw )

133. Asthma Treatment
Summary
Mild Intermittent
Use: Albuterol, Asthma Action Plan
Mild Persistent
Use: Albuterol and Controller medications (low dose
steroids, nedocromil, cromolyn, montelukast)
Moderate Persistent
Use: Combination of medications (low to medium dose
steroid plus long acting beta agonist, and/or Leukotriene
modifiers)
Severe Persistent
Use: High dose inhaled steroids, long acting beta
agonist, and leukotriene modifier. May need oral
steroids

135. WARNINGS
 BETA BLOCKERS even topical or selective
may precipitate asthma
 Can be fatal  so contraindicated
 Overuse of beta2 agonists  can cause
asthma related deaths

138. COPD
 INCOMPLETELY reversible airway obstruction
and mucus hypersecretion
 Disease of smaller airways
 Same drugs used
 Antimuscarinics are more effective
 Moderate to severe disease – use inhaled
steroids + long-acting beta2 agonists
 Thophylline for severe cases ( careful in elderly
)
 Mucolytics for recurrent, prolonged, severe
cases

141. INFECTION in COPD
 No prophylaxis
 If URI comes  Amoxicillin or Co-amoxiclav or
cotrimoxazole
 Influenza vaccine in winter
 Bronchospasm  Ipratropium
 Hypoxia  24% O2, increasing slowly
 Dehydration  fluids
 Cardiac failure  O2, diuretics
 Respiratory stimulants  doxapram 1- 4
mg/mind IV

142. ROUTES OF DRUG DELIVERY

143. INHALED ROUTE
 Preferred mode of delivery
 Has direct effect on airways
 Lower risk of systemic side effects
( particularly with steroids )
 Rapid onset of action ( bronchodilators)

144. DELIVERY DEVICES
 PRESSURIZED METERED-DOSE INHALERS
(pMDI)-
 Convenient, portable, delivers 100-400 doses,
patients should be taught how to use
 SPACE CHAMBERS – reduces local,
systemic side effects, useful in children
 DRY POWDER INHALERS –( insulin
delivery), co-ordination not necessary
 NEBULIZERS –JET, ULTRASONIC- Delivers
higher doses of drugs, useful in extreme
obstruction, in children

152. PHARMACOTHERAPY
OF COUGH

153. the velocity of cough!
 It’s at 60 miles per hour

154. When a human coughs, the droplets that comes out can
travel a distance of up to three feet.

156. COUGH
 It is a protective reflex
causing expulsion of
respiratory secretions
or foreign particles
from air passages.

157. COUGH
Useful cough should
be allowed
Useless cough
should be stopped

161. TREATMENT APPROACH
REMOVAL OF THE CAUSE -
tt of asthma, postnasal drip
 Expectorants
 Antitussives

164. NON SPECIFIC THERAPY
 Pharyngeal demulcents: Lozenges, cough
drops, syrup containing glycerin, liquorice
 sooth the throat
 Promote salivation
 Decrease afferent impulses
 provide symptomatic relief in dry cough arising
from throat.

168. EXPECTORANTS
(MUCOKINETICS)
 increase bronchial secretion
 reduce it’s viscosity
 Loosen cough
 Bring sputum out

171. GUIACOL
 Derivative  Guaiphenesin
 increase bronchial secretion and mucosal ciliary
action.

172. MUCOLYTICS
BROMHEXINE
 obtained from adhatoda vasica.
 Potent mucolytic
 Mucokinetic
 Induce thin copious bronchial secretion
 It depolymerises mucopolysaccharides and
liberate lysosomal enzymes  thereby breaks
fibres in thick sputum.
 Useful when mucus plugs are present.

175. BROMHEXINE
 Side effects- Rhinorrhoea, lacrymation,
gastric irritation
 patients with bronchiectasis  sputum thick
 difficulty in clearing  bromhexine helpful

178. AMBROXOL
 Metabolite of bromhexine
 similar

180. ACETYLCYSTEINE
 Opens disulfide bonds in mucoproteins
present in sputum  makes it less viscid
 not popular
 administered directly into respiratory tract
 more side effects

181. CARBOCISTEINE
 action like acetyl cysteine
 orally or inhalation
 useful when viscous secretion is a problem
( cystic fibrosis, tracheostamies )
 Side effects - GI irritation, rashes
 available in combination with amoxicillin for
bronchitis, sinusitis, bronchiectasis (carbomox)

185. Water inhalation
 Via an aerosol (breathing over a hot basin)
 Cheap and effective in bronchiectasis
 promote secretion of dilute mucus  Gives
protective coating to the inflamed mucous
membrane.
 Menthol and eucalyptus - gives therapeutic
smell
 Simple hydration of a dehydrated patient have a
beneficial effect

189. OTHER EXPECTORANTS
 Sodium and potassium citrate
Potassium iodide
 Iodine hypersensitivity  dangerous
 interferes with thyroid function tests.
 Iodism
 Goiter
 less popular
 Ammonium salts cause nausea

194. ANTITUSSIVES
 Raise the threshold of cough centre in CNS
 Or decrease cough impulses peripherally
 Used only for dry unproductive cough
 If cough is tiring
 or disturbs sleep
 or hazardous (hernia, piles, cardiac disease,
ocular surgery)

198. OPIOIDS- CODEINE
 Opium alkaloid
 More selective for cough centre
 Standard antitussive
 Suppress Cough for 6 hrs
 Low addictive liability
 Analgesic for moderate pain
 Side effects: Constipation, drowsiness.
 higher doses  respiratory depression
 C/I: Bronchial asthma, in diminished respiratory
reserve
 Preparation: Syrup codeine phos 4-8ml linctus

204. PHOLCODEINE
 Not an analgesic
 no sedation
 no addiction
 efficacy similar to codeine
 longer acting (12hrs or more )
 Morphine  high abuse liability
 Methadone or diamorphine linctus preferred in
advanced bronchial carcinoma

208. NON OPIOIDS - NOSCAPINE
 No analgesic and dependence inducing
properties.
 Equipotent as codeine.
 Specially useful in spasmodic cough.
 Side effects: release histamine  broncho
constriction.

210. DEXTROMETHORPHAN
 Synthetic compound
 increase threshold of cough centre
 effective as codeine
 Does not depress mucociliary function of
airways.
 No constipation.
 No addiction.
 S/E: drowsiness, ataxia.

214. ANTIHISTAMINES
 conventionally added to antitussive/ expectorant
formulation.
 Lack selectivity for cough centre.
 No expectorant action
 for cough in respiratory allergic states.
 Chlorpheniramine, Diphenhydramine
Promethazine
 IInd generation ineffective.

217. CETIRIZINE
 Penetrate brain poorly
 Not metabolized
 Also inhibits release of histamine – extrabenefit
in allergic disorders
 Higher and longer lasting concentration in skin
 Once daily dose
 Does not produce arrhythmias
 Levocetirizine effective at half the dose

221. AZELASTINE
 has good topical activity
 inhibits histamine release and inflammatory
reaction triggered by LTs, PAF
 bronchodilator
 Downregulate ICAM – 1 expression
 Long acting
 Given by nasal spray for allergic rhinitis
 Side effects – stinging , altered taste

225. BRONCHODILATORS
 Should be used only  when
bronchoconstriction is present.
 combinations with antitussive  not
satisfactory.

228. AEROMATIC CHEST RUB
 Widely advertised
 No evidence of benefit in pathological cough.
 Reduce experimentally induced cough

229. LOCAL ANAESTHETICS
 benzonatate
 Nebulized lignocaine  reduce coughing
during fiberoptic bronchoscopy
 Intractable cough in bronchial carcinoma.

232. SPECIFIC TREATMENT
APPROACHES TO COUGH
Etiology of cough
 Upper/ lower respiratory tract
infection
 Smoking/ chronic bronchitis
 Pulmonary tuberculosis
 Asthmatic cough
 Postnasal drip due to sinusitis
 Postnasal drip due to allergic/
perennial rhinitis
 Gastro esophageal reflux
 ACE inhibitor associated cough
Treatment approach
 Appropriate antibiotics
 Cessation of smoking/ avoidance of
pollutants
 Antitubercular drugs
 Inhaled Beta2 agonists/ipratropium/
corticosteroids
 Antibiotic, nasal decongestant,
H1 antihistaminic
 Avoidance of precipitating factor (s),
corticosteroid nasal spray
 Bed head elevation, light dinner, diet
modification, H2 blocker, omeprazole,
Metoclopramide
 Substitute ACE inhibitor by losartan

235. RESPIRATORY STIMULANTS
( DOXAPRAM, AMINOPHYLLNE )
 Doxapram – increases rate and depth of
respiration
 Almitrine
 Useful In acute exacerbations of chronic lung
disease with hypercapnia
 In conjunction with assisted ventilation
 Overdose with sedatives, post-anaesthetic
respiratory depression
 apnoea in premature infants( aminophylline,
caffeine)

236. CONTRAINDICATIONS
 Epilepsy
 IHD
 Hypertension
 Thyrotoxicosis
 Status asthmaticus

237. PULMONARY SURFACTANT
 RDS  failure to produce natural surfactant
 Colfosceril palmitate, poractant alpha,
beractant
 Given by intratracheal instillation
 Useful in neonates with RDS

238. OXYGEN THERAPY
INDICATIONS
 Inadequate oxygenation due to MI ,
Pulmonary Disorders , drug overdose ,
trauma, in acutely ill patient
 High conc. of O2  TYPE I respiratory failure
( low PaO2 with normal or low PaCO2)
 Low conc. Of O2  TYPE II respiratory failure
(low PaO2 with raised PaCO2)( patients with
COPD )

239. OXYGEN THERAPY
 Continuous long-term domiciliary O2 therapy –
(LTOT)
 For patients with severe hypoxaemias
 Cor pulmonale
 Improve survival

240. REC0MMENDED CRITERIA
 PAO2 less than 7.3 kPa
 PACO2 more than 6.0 kPa
 FEV1 less than 1.5L
 FVC less than 2.0 L

241. COMPLICATIONS OXYGEN
THERAPY
 Promote absorption atelectasis
 Depress ventilation
 Irritation of mucosal surfaces
 Fire hazard

242. PNUMONIAS
 Community-acquired
 Hospital- acquired – I.V BSA ( eg cefuroxime )
 ANTIBIOTICS – depending on the organism 
Amoxicillin, azithromycin , doxycycline,
flucloxacillin , cephalexin, gentamicin +
cephalosporin
 ROUTES  oral , parenteral ( SEVERE )
 DURATION  7-10 days usually , 2-3 weeks in
some
 OXYGEN – in severe hypoxia
 FLUIDS – if dehydration

243. DRUGS FOR PULMONARY
ARTERIAL HYPERTENSION
 Mostly secondary
 O2 to correct hypoxia
 Diuretics initially for right heart failure
 Continuous I.V infusion of Prostacyclin (PG
I2; epoprostenol )
 Endothelin receptor antagonists – Bosentan,
ambrisentan – (requires LFTs monitoring )
 Phosphodiesterase 5 inhibitors – sildenafil ( 20
mg tid orally), tadalafil ( od )

244. SUMMARY
 Most antiasthma treatment is with glucocorticoids
and beta2 agonists
 Aggressive use of glucocorticoids, especially by
inhaled route is the keystone of stepped approach
 Smoking cessation and long-term treatment with
oxygen are the only measures known to improve
survival in COPD
 Antihistamines have a wide role in allergic
disorders
 2nd generation antihistamines do not cause
sedation unlike 1st generation

246. SUMMARY
 If cough is irritating and unproductive -
suppress it
 productive and difficulty in expectoration –
use expectorants
 Treat the underlying condition
 Use codeine, pholcodine when dry cough is
disturbing sleep.

247. SUMMARY
 Morphine, diamorphine  useful in patients
with terminal illness.
 Steam inhalation with or without menthol is
soothing and harmless to aid expectoration.
 Mucolytic expectorants are no better than
steam inhalations.
 Other expectorants are toxic and of no value.

249. THANK U…