Drugs Affecting Respiratory System center or locally as an anesthetic or to increase

secretion and buffer irritation.

Drugs Acting on the Upper Respiratory Tract
- Antitussive drugs can cause CNS depression,
including drowsiness and sedation.
- Antitussive drugs should be used with caution in
any situation in which coughing could be
important for clearing the airways.
Productive vs. Non-productive (dry)
Productive: lower respiratory from bacterial infection
Non-productive = higher respiratory from viral infection
Antitussive Drugs
- The traditional antitussives include codeine,
hydrocodone (Hycodan), and dextromethorphan
(Benylin), which act directly on the medullary
cough center of the brain to depress the cough
reflex.
- They are centrally acting; they are not the drugs
of choice for anyone who has a head injury or
who could be impaired by central nervous
system (CNS) depression.
- Other antitussives have a direct effect on the
respiratory tract. Benzonatate (Tessalon) acts as
a local anesthetic on the respiratory passages,
lungs, and pleurae, blocking the effectiveness of
the stretch receptors that stimulate a cough
reflex.
- All of these drugs are indicated for the treatment
of nonproductive cough.
Contraindications
- Antitussives are contraindicated in patients who
need to cough to maintain the airways.
E.g.:
- postoperative patients (to avoid respiratory
Streptococcus = gram positive bacteria distress)
If condition is not treated it could progress into a lower - asthma and emphysema (because cough
respiratory tract suppression in these patients could lead to an
accumulation of secretions and a loss of
Lower Respiratory tract: (community or hospital respiratory reserve)
acquired) pneumonia (infection in both or one lung of - hypersensitive to or have a history of addiction
the patient (the entire lung) = common in pediactric, to narcotics (codeine, hydrocodone) (Codeine is
bronchitis, COPD = barrel chested, common in adult a narcotic and has addiction potential).
patient if they are smokers for a long period of time. - Patients who need to drive (these drugs can
Aspirin = acetylcysteine cause sedation and drowsiness).
Antitussives - Pregnancy and lactation (potential for adverse
effects on the fetus or baby, including sedation
- Antitussive drugs suppress the cough reflex by and CNS depression)
acting centrally to suppress the medullary cough
Decongestants
- decrease the overproduction of secretions by
causing local vasoconstriction to the upper
respiratory tract thereby reducing blood flow to
the mucous membranes of the nasal passages
and sinus cavities.
ADVERSE EFFECTS:
- rebound vasodilation-congestion (rhinitis
medicamentosa)-due to prolonged overuse of
decongestants.
Decongestants: Indication
ANS Controlled Processes
• Shrink engorged nasal mucous
• Relieve nasal stuffness - BP
• Relief of nasal congestion associated with: - Heart and Breathing rates
- Acute/chronic rhinitis - Body temperature
- Common cold - The balance of water and electrolytes (such as
- Sinusitis sodium and calcium)
- Hay fever - The production of body fluids (saliva. sweat, and
- Other allergies tears)
• May also be used to reduce swelling of the nasal - Digestion
passage and facilitate visualization of the - Urination
nasal/pharyngeal membranes before surgery or - Defecation
diagnostic procedures. - Sexual response

Topical Nasal Decongestants Autonomics: Neurological Model

- The topical nasal decongestants include Sympathetic Parasympathetic

ephedrine (Pretz-D), oxymetazoline (Afrin, Dilate pupils (mydriasis) Constrict pupils (miosis)
Reduced saliva flow Increased saliva flow
Allerest), phenylephrine (Coricidin),
Increased heartbeat Slow heartbeat
tetrahydrozoline (Tyzine), and xylometazoline
Relax airways Constrict airways
(Otrivin}.
Inhibit activity of Stimulate activity of
- are sympathomimetics, meaning that they stomach stomach
imitate the effects of the sympathetic nervous Liver puts out glucose Liver releases bile
system to cause vasoconstriction leading to Relax gallbladder Contract gallbladder
decreased edema and inflammation of the nasal
membranes.
Oral Decongestants
- The only oral decongestant currently available
for use is pseudoephedrine (Triaminic Allergy
Congestion, and many combination products).
Topical Nasal Steroid Decongestants
- include beclomethasone (Peciovent), budesonide
(Pulmicort), dexamethasone (Decadron),
flunisolide (AeroBid), fluticasone (Flovent), and
triamcinolone (Azmacort).
- Block the inflammatory response and are
preferred for patients with allergic rhinitis for
whom systemic steroid therapy is undesirable.
CONTRAINDICATED Cough Suppressants
- Acute infection Over the counter antitussive
Antihistamines - Dextromethorphan (non-opioid)
- Opioid derivative without the euphoria in normal
- block the release or action of histamine, a
dosage
chemical released during inflammation that
- When abused-PCP like drug trip
increases secretions and narrows airways.
- Found in many combination cold medicines
Anaphylactic shock = (severe allergic reaction) severe
Prescription antitussive (opioid)
condition where the patient can't breath properly and
lead to death - Codeine
- Most effective for treating cough
Medications for Allergic Rhinitis and Cough
- 1/10th the dose used for pain
Antihistamines, Intranasal Medications, and
What is a risk of using a sympathomimetic
Sympathomimetics (Decongestants)
decongestant?
What is Allergic Rhinitis?
- Sympathomimetic decongestants are drugs that
- Inflammatory response to allergens that involves "mimic the sympathetic nervous system (SNS)
the upper respiratory tract. which causes vasoconstriction.
- Seasonal or perennial.
What types of patients are most at risk for
- Symptoms can include: Swollen sinuses,
sympathomimetic decongestant?
Itchy/watery eyes, stuffy or runny nose and
itchy/sore throat. - Patients with cardiac disease and/or high blood
pressure. The vasoconstriction is not safe for
Medications to Treat Allergic Rhinitis
them as their blood pressure is already elevated
• Antihistamines (oral and intranasal) and it could increase their cardiovascular risk.
- First generation-diphenhydramine (sedating) There are over the counter decongestants made
- Second generation-fexofenadine, loratadine, especially for patients with hypertension or
cetirizine (non-sedating cardiovascular disease that are not
• Intranasal glucocorticoids sympathomimetics.
- First generation (more systemic effects) THERAPEUTIC ACTIONS
beclomethasone, budesonide, triamcinolone.
- Second generation (less systemic effects) - selectively block the effects of histamine at the
ciclesonide, fluticasone propionate. histamine-1 receptor sites, decreasing the
• Sympathomimetic decongestants allergic response.
- They also have anticholinergic (atropine-like) -
Sympathomimetic Decongestants inhibit the action of parasympathetic effects and
Sympathomimetic = Mimics the sympathetic system antipruritic effects.
- used for the amelioration of allergic reactions to
Sympathomimetic Decongestants blood or blood products, for relief of discomfort
associated with dermographism, and as
Phenylephrine-nasal spray or oral
adjunctive therapy in anaphylactic reactions.
Pseudoephedrine-oral
Antihistamine: Contraindication
- Cause vasoconstriction of nasal blood vessels by
- Hypersensitivity
activating alpha 1 receptors
- Hypertension
- Use with caution in cardiovascular patients
- Cardiovascular disease
- Shrinks swollen membranes - eases breathing
- Urinary retention
- Potential for abuse/adverse effects .
- Increased ocular pressure
- Pseudoephedrine ingredient in crystal meth
- Wean intranasal spray - use only for a few days
Antihistamine: Side effects Drugs Acting on the Lower Respiratory Tract
- Sleepiness (drowsiness)
- Reduced coordination
- Reaction speed and judgement
Antihistamine: Adverse Effects
Anticholinergic (drying) effects, most common:
- Dry mouth
- Difficulty urinating
- Constipation
- Changes in vision
Expectorants
- Expectorants are drugs that liquefy the lower
respiratory tract secretions. They are used for the
symptomatic relief of respiratory conditions
characterized by a dry, nonproductive cough.
- EX. Guaifenesin
- ADVERSE EFFECTS: GI SYMPTOMS eat
small frequent meals
KEY POINTS
- Expectorants are drugs that liquefy the lower
respiratory tract secretions. They are used for the
symptomatic relief of respiratory conditions
characterized by a dry, nonproductive cough.
- Guaifenesin is the only expectorant currently
available. Care should be taken to avoid
inadvertent overdose when using OTC products
that might contain this drug.
Mucolytics
- increase or liquefy respiratory secretions to aid
the clearing of the airways in high-risk
respiratory patients who are coughing up thick,
tenacious secretions. Patients may be suffering Bronchodilators
from conditions such as chronic obstructive - Or antiasthmatics, are medications used to
pulmonary disease (COPD), cystic fibrosis, facilitate respiration by dilating the airways.
pneumonia, or tuberculosis. - They are helpful in symptomatic relief or
- Affects the mucoproteins in the respiratory prevention of bronchial asthma and for
secretions by splitting apart disulfide bonds that bronchospasm associated with COPD.
are responsible for holding the mucus material
together. The result is a decrease in the tenacity Xanthines
and viscosity of the secretions.
- Xanthines used to treat respiratory disease
- Domnase alfa is a mucolytic prepared by
include aminophylline (Truphylline), caffeine
recombinant DNA techniques that selectively
(Caffedrine), dyphylline (Dilor), and
break down respiratory tract mucus by
theophylline (Slo-Bid, Theo-Dur).
separating extracellular DNA from proteins.
- have a direct effect on the smooth muscles of the
respiratory tract, both in the bronchi and in the
blood vessels.
BRONCHODILATORS AND ANTI- Recognize, be alert and watch for the signs and
INFLAMMATORIES ASTHMA AND COPD symptoms of a patient having an asthma attack!
Respiratory Smooth Muscle It is important to evaluate the effectiveness of
medication treatment plans.
- Oxygen is inhaled through the mouth or nose.
- Travels down the bronchi and bronchioles to be Meds to Treat Both Asthma Airway Problems
exchanged with CO2 in the alveolar capillaries.
- Smooth muscle is found in the walls of the
bronchi and bronchioles.
- Bronchioles are smooth muscle tubes that impact
flow of air through dilating or constricting.
Respiratory Diagnoses: Asthma
Asthma patients have 2 airway problems
1. Bronchoconstriction
- Smooth muscle contraction
2. Inflammation
- Immune response triggered by response to
allergens
- Airways become inflamed
- Excess mucus
- Narrowed airway
Asthma - Chronic Inflammatory Disease
- Patient is exposed to an allergen and it binds to
IgE antibodies on mast cells.
- Mast cells release their mediators (histamine.
leukotrienes, Interleukins, prostaglandins).
- Mast cell mediators cause bronchoconstriction
and the inflammatory cells infiltration
(eosinophils, leukocytes, macrophages.
Bronchoconstriction
- These inflammatory cells respond (release their
cytokines, leukotrienes, interleukins). Emergency/Rescue Inhaled long acting
- Airways are hyperreactive, Inflamed, and have Inhalers
excess mucus. SABAs (Short- LABAs (Long-Acting Beta 2
Acting Beta 2 Agonists)
Clinical Symptoms of Asthma Agonists) - Arformoterol
Exposure to triggers leads to bronchospasm - Albuterol - Formoterol
- Levalbuterol - Indacaterol
- Airways are ever more narrowed - Salmeterol
- Chest feels "tight" Beta agonist/cholinergic
- Hard to catch your breath antagonists
- Breath sounds- wheezes, or a high pitched - Albuterol/ipratropium
whistling sound on inhaling
- Cough Inflammation
- May feel dizzy or light-headed
- Ask "Do you feel like you can catch your breath Inhaled glucocorticoids Anti-leukotriene
better now? modifiers (oral)
- Is the wheezing going away? . - Beclomethasone - Montelukast
- Ask "Does your chest still feel tight? dipropionate - Zafirlukast
- Budesonide - Zileuton
- Has the cough lessened?
- Ciclesonide Mast cell stabilizers
 - Flunisolide - cromolyn Only use SABAS for rescue inhalers!
- Fluticasone
propionate Beta agonist/cholinergic agonists
- Mometasone - Albuterol/Ipratropium
furoate
Methylxanthines
If a patient is going to do something that exacerbates - Theophylline
their asthma, medicate them before that time to minimize - Aminophylline
their reaction.
Bronchoconstriction: SABA vs LABA
✓ Asthma is a chronic disease process.
✓ Smooth muscle in the respiratory system causes SABA (Short-acting Beta 2 Agonists)
bronchoconstriction of already narrowed - Effects felt almost immediately, peak 30-60
airways. minutes, last 3-5 hours
✓ The inflammatory response causes excess - For > 1 puff wait 1 minute between puffs
mucus. - If poor response with inhaler, consider nebulizer
✓ The medication needs to address both (more time for bronchodilation)
inflammation and bronchoconstriction. - Treatment goal of SABA for exacerbations
✓ During acute attacks - prioritize the SABAS primarily
✓ For prevention of attacks, use LABAs and - Side effects - tachycardia, angina and tremors
glucocorticoids or leukotriene modifiers, or
cromolyn. LABA (Long-acting Beta 2 Agonists)

Medications to Treat Bronchoconstriction - Onset varies with drug, used for long-term
control
Beta 2 receptor agonists - Should not be used as monotherapy
(mimic sympathetic nervous system stimulation) - Glucocorticoid should also be part of medication
plan
- Side effects: tachycardia, chest pain, and tremors - Consider combo inhaler
Beta 2 receptors located on Bronchoconstriction: Methylxanthines
- Bronchial smooth muscle/uterine muscle Example: Theophylline
Cause smooth muscle to relax - Causes bronchodilation by relaxing smooth
muscle
- Bronchodilation - inhaled route less systemic
- Also causes CNS excitation, vasodilation,
effects
diuresis
- Uterine relaxation (our focus is on the lungs)
- Usually oral dose, but also IV
Emergency/rescue inhalers - Less effective than Beta 2 agonists but longer
duration
- SABAS (Short-acting Beta 2 Agonists)
- Narrow therapeutic window-target 5-15 mcg/mL
- Albuterol
- Levalbuterol REMEMBER
Inhaled long acting THEOPHYLLINE - food to avoid with this drug, avoid
drinking coffee, caffeine, cola, and chocolate milk.
- LABAS (Long-acting Beta 2 Agonists)
- Arformoterol - Serious toxic effects (cardiac dysrhythmias,
- Formoterol convulsions) most likely at 30+ mcg/mL
- Indacaterol - Used to be standard therapy, now not first choice
- Salmeterol unless other options not readily available
- Caffeine- also methylxanthine family/ limit
We use SABAs and LABAS to help us relieve while on this medication
bronchoconstriction by bronchodilating for the patient.
Bronchoconstriction: Anticholinergics - LMs suppress the constriction and inflammatory
response.
- MOA-block muscarinic receptors in lungs-
- They're often added on when glucocorticoids
decreases bronchoconstriction.
aren't enough.
- Off-label use for asthma - more use with COPD
- Examples: montelukast, zafirlukast, zileuton
- Examples: ipratropium, tiotropium
Remember the ending -ukast as anti-leukotriene or
Adverse effects!
leukotriene modifiers.
- Relatively minimal systemic Leukotriene modifiers - adverse Effects:
- Dry mouth
- Irritation of pharynx - All 3 may cause neuropsychiatric effects
(irritability. bad dreams, depression, insomnia,
Medications to Treat Inflammation Prevention of etc.)
Asthma Attacks - Mild GI distress
Combination Inhalers Corticosteroid/LABA - Zileuton may impact liver. Monitor ALT levels
regularly
Anti-inflammatory and bronchoconstriction
Cromolyn
- Not "for rescue" inhalers- prevention only
- Budesonide/formoterol - Inhaled medication
- Fluticasone/salmeterol - Mast cell stabilizer
- Fluticasone/vilanterol - Suppresses inflammation- does not relieve
- Mometasone/formoterol bronchoconstriction
- Used for prevention, NOT treatment of acute
Make sure your patients are more effectively educated! attack Also used before exercise to treat
Medications to Treat Inflammation exercise-induced asthma (SABA can also be
used for El asthma)
Glucocorticoids
Cromolyn-adverse effects:
- Normally produced by the adrenal cortex in the
body - Essentially none
- Can be given as medications by inhaled, oral, or Omalizumab
IV routes
- Used to prevent asthma attacks -not rescue - IgE antagonist
inhalers - Must be given SubQ
- Given on FIXED schedule not PRN (pro re nata) - 2nd line drug for allergy-related asthma
- Suppress inflammation (helps both COPD and - High cost (310.000/year)
asthma) Respiratory Medications COPD Emphysema and
Partner is aldosterone chronic bronchitis

Glucocorticoids-adverse effects Respiratory Diagnoses: COPD

- Mimic the effects of Cushing's Chronic bronchitis

- Moon face, facial hair, mood swings, buffalo - Chronic inflammation of the bronchial tubes
hump, potential for increased fluids, changing - Thickened mucus and SOB
fat distribution, difficult on bones and skin,
- Bacterial colonization in respiratory tract
suppresses growth in children.
- See Endocrine drug presentation for more details Emphysema
- Watch for adrenal gland
- Alveoli are damaged and enlarged
Leukotriene modifiers - Alveolar walls are destroyed
- Air is trapped limits fresh air entry
- Leukotrienes promote smooth muscle
constriction and inflammatory response.
 - Phosphodiesterase type 4 Inhibitors-roflumilast
- Severe COPD
Unique Delivery Methods for Respiratory
Medications and PEFR peak expiratory flow rate
Monitoring

Clinical Symptoms of COPD

Emphysema and chronic bronchitis
- Air trapping
- Damaged tissue for CO2-O2, exchange
Chronic symptoms:
- Difficulty breathing
- Lower oxygen levels
- Higher carbon dioxide
- Cough
- Right-sided heart failure (Cor Pulmonale)
Why would the right side of my heart get bigger, or have
failure because of the lungs being damaged?
The pressure in your lungs is getting higher.
The right side of the heart is pumping blood to your
lungs.. when the pressure in the lungs is elevated
because of the COPD, the heart has to push harder/work
harder to get blood through the lungs. In order to do this,
the heart hypertrophies (gets bigger) to try to
compensate for the extra workload of pushing blood
through the lungs with COPD... Ways to Administer Respiratory Medications

…until it works initially until the heart gets so Inhalation

overloaded that it eventually gets floppy and less
- MDI-Metered Dose Inhaler
effective.
- Consider using spacer
Bronchodilators - Nebulizer
- Requires mechanical equipment
- Stable COPD - Dry micronized powder inhalers
- Bronchodilators - No need for spacers
- Stable COPD Inhaled short-acting SABAS or
anticholinergics Oral medications
- Exacerbation COPD
- More systemic effects
- SABAs
- Used when inhaled alone isn't effective
Glucocorticoids Intravenous (IV) medications
- More systemic effects
- Stable COPD-given with long acting LABA - Used when inhaled alone isn't effective
combination
- Monotherapy not recommended
Subq - Easy to use with children age 5 and older
- Measures the force a patient can expel air from
- Only one med currently
their lungs
- Omalizumab-IgE antagonist
For less systemic effects, give the medication as an
inhaler.
When inhalers alone don't work, add oral medication but
be aware you are also adding more systemic effects!
How to Use an (MDI) Metered Dose Inhaler
1. If the inhaler is new or hasn't been used for a
while, shake inhaler well, then aim away from
the face and spray 3-4 puffs.
- You want to make sure they have adequate
medication available to them.
2. Exhale completely with a long breath and then
place the inhaler in the front of your mouth
(canister should be upright).
- You want to empty their lungs as much as
possible, so that the air they are replacing it with
is full of medication.
3. Open your mouth, start breathing in slowly and
deeply as you firmly press down on the top of
the canister.
4. Hold your breath for 10 seconds.
5. Wait at least 1 minute between putts for the 2
puff.
6. Wait at least 5 minutes between bronchodilator
and anti-inflammatory.
Walk your patient through these slowly and ask them to Asthma:Patient Teaching
do it along with you without an inhaler.
- Ensure pt is able to self administer the
Spacers medication.
- Small chamber that attaches to the inhaler - Provide demonstration/return demonstration.
- Medication from an MDI is sprayed into the - Pt knows the correct time and intervals for the
spacer. inhalers
- Then medication is slowly inhaled into lungs. - Provide spacer if p has difficulty coordinating
breathing with inhaler activation.
What is a Nebulizer? - Ensure pt knows how to keep track of the no. of
doses in the inhaler device.
- A nebulizer turns liquid medication into a mist
that the patient can breathe into their lungs! B-Agonist: Nursing Implication
Peak Exploratory Flow Rate - Monitor Therapeutic effects
- Decreased dyspnea, wheezing, restlessness,
- Can be done in community
anxiety.
- Should be correlated with a written plan for
- Improve respi patterns with return to normal rate
medication adjustment based on monitor
and quality, activity tolerance
readings
- Pt should know how to use inhalers and MDI's
Peak Flow Meter - Through assessment before beginning therapy.
- Pt should be encouraged to have good health
- Small and portable - Get prompt treatment for flu or other illness
 - Skin color, baseline vs, respi (between 12 and 24 Isoniazid
bpm), respi assessment include PO2, Sputum
I- Interferes with absorption of B6 Low
production, allergies, hx of respi problems, other
Vitamin B6-Peripheral Neuropathy
meds
N- Neuropathy REPORT:
- Avoid exposure to conditions that precipitate
- New numbness
bronchospasm (allergies, smoking, stress, air
- Tingling extremities
pollution)
- Ataxia
- Adequate fluid intake
- Compliance with med treatment H- Hepatoxicity REPORT IMMEDIATELY
- Avoid excessive fatigue, heat, extreme temp,
caffeine - Jaundice (Skin/Sclera)
- Get vaccinated against pneumonia and flu - Dark urine
- Check with physicians before taking meds - Fatigue
including OTC's - Elevated liver enzymes
- Teach to take bronchodilators exactly as - Hold medication
prescribed. - TEACH: no alcohol and acetaminophen

Anti-tubercular Drugs Tuberculosis Pyrazinamide

Tuberculosis (TB) is a bacterial infection spread through 1. Causes hyperuricemia

inhaling tiny droplets from the coughs or sneezes of an 2. These excess uric acid deposit at joints forming
infected person. It mainly affects the lungs, but it can uric acid crystals thus causing gout.
affect any part of the body, Including abdomen, glands, REPORT:
bones and nervous system.
- Nausea
RIPE - Vomiting
- Rifampicin - loss of appetite
- Isoniazide - mild muscle/joint pain
- Pyrazinamide Ethambutol
- Ethambutol
Report:
Anti-tubercular Drugs: Indication
- Blurred vision
- treatment of Mycobacterium tuberculosis - Color changes (Blue Green)
infections.
TEACH:
Mechanism of action
- Baseline eye exam and routine eye exams
- Act by reversibly inhibiting DNA-dependent
RNA polymerase, which further inhibits Streptomicicn- antibiotic medication that cna kill
bacterial protein synthesis and transcription. different forms of bacteia (gram psitive or negative)

Rifampicin ALL FOUR OF THESE DRUGS CAUSE

HEPATOXICITY
1. NORMAL
- Red, orange: tears, urine, sweat
TEACH
- Wear glasses instead of contacts due to
discoloration of tears.
2. Oral contraceptives ineffective.
- Inform client to use non-hormonal back- up birth
control
3. Monitor for jaundice.