Bronchodilators & Other Respiratory Drugs Chp 37

L. Lopez, MSN, RN,C, D(c)

Diseases of the Lower Respiratory Tract

COPD
Emphysema Chronic bronchitis

Asthma

Bronchodilators and Respiratory Drugs

Bronchodilators

Beta-adrenergic agonists Xanthine derivatives Anticholinergics Leukotriene receptor antagonists Corticosteroids

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Bronchodilators
Relax smooth muscle to dilate bronchi & bronchioles 3 classes: Beta-agonists, anticholinergics, xanthine derivatives Have no effect on inflammation

Beta-Adrenergic Agonists

Large group, sympathomimetics Used during acute phase of asthmatic attacks Quickly reduce airway constriction and restore normal airflow Stimulate beta2-adrenergic receptors throughout the lungs [_____________________] Drugs: end with -terol Albuterol [Proventil/Ventolin] SABA Pirbuterol [Maxair] SABA Salmeterol [Serevent] LABA Formoterol (Foradil] LABA Metaprotenerol [Alupent}-SABA Levalbuterol [Xopenex] -SABA Epinephrine [Adrenalin} Terbutaline [Brethine]

Drug Profile

Albuterol [Proventil]: Most commonly used

Route: inhalational [MDI, solutions] & oral

Salmeterol [Serevent]
Maintenance tx asthma/copd 12 h duration of action Frequency: 1 puff twice daily maintenance only Available: poweder for inhalation alone [Serevent Diskus] or combo with corticosteroid [Advair Diskus]
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Mechanism of Action

Dilate airways by stimulating beta-2 adrenergic receptors in the lungs: 3 Types

Nonselective adrenergic drugs:
Stimulate beta, beta-1 [cardiac] & beta-2 [respiratory] receptors: Epinephrine

Nonselective beta-adrenergic drugs

Stimulate both beta-1` & beta-2 receptors: metaproterenol [Alupent], Isoproterenol [Isuprel]

Selective beta-2 drugs Primerily Stimulate beta-2 receptors: albuterol [Proventil]

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Mechanism of Action

Beta-2 adrenergic agonists bind to B-2 receptor to cause an increase in cyclic adenosine monophosphate [cAMP]= pulmonary smooth muscle relaxation.
Dilation of airways Increased airflow

Mechanism of Action

Short-acting beta-2 adrenergic agonists [SABA]

Rapid, short-term relief_____________ drugs: acute attack & prior to activity or exercise Used for COPD pt when more breathless than usual

Long-acting b-2 adrenergic agonists [LABA]: _________________________

Used for prevention of asthma attack COPD pt: taken daily to maintain open airways

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Indications
Relief of bronchospasm Used in treatment and prevention of acute attacks Used in hypotension and shock Used to produce uterine relaxation to prevent premature labor [terbutaline [Brethine[

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Adverse Effects
CNS:

insomnia, restlessness, nervousness, vascular headaches, tremors Cardiac stimulation: palpitations, HTN, tachycardia, anginal pain Hyperglycemia, dry mouth, anorexia,bad taste in mouth.
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Contraindications & Interactions

Contraindications
Drug allergy Uncontrolled cardiac dysrhythmias High risk of stroke [vasoconstrictive properties]

Interactions
MAO inhibitors/other sympathomimetics: enhanced risk HTN Diabetics: hyperglycemia
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Anticholinergics [Cholinergic Antagonists]

Ipratropium bromide [Atrovent]: Preg. B Tiotropium [Spiriva]: preg. C [LABA] Prevention drugs [Maintenance drug] Relieves bronchospasm by blocking muscarinic receptors in lung. Must take on a daily basis to prevent asthma attack, reduce airway blockage in COPD. Do not use during acute attack or exacerbations
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Drug Profile

IPRATROPIUM [ATROVENT] LABA Atropine-derivative, muscarinic antagonist Route: Inhalation Used: approved only for COPD [bronchospasm]; asthma [unlabeled use] CONTRAINDICATION: PEANUT ALLERGY: SHOULD AVOID IPRATROPIUM ALONE & COMBIVENT [IPRATROPIUM/ALBUTEROL]

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Mechanism of Action
Block muscarinic receptors in bronchi = bronchial dilation Block parasympathetic NS [Ach receptors] Prevent bronchoconstriction/bronchospasm Bind to mucous membranes receptors & decrease airway secretions.

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Indications
Bronchospasm

associated w/chronic bronchitis Emphysema: COPD Prevent asthma attack

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Contraindications/Interaction
Drug allergy Soy or atropine allergy Peanut oils, peanuts, soybeans, legumes (beans) Peanut allergy Interaction Additive toxicity if taken with other anti-cholinergic agents

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Adverse Effects
Dry mouth or throat/irritation pharynx Nasal congestion Heart palpitations Gastrointestinal distress Urinary retention Increased IOP Headache Coughing Anxiety

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Bronchodilators

Sympathomimetics-Non-selective betaadrenergic agonist; vasopressor

Epinephrine (adrenaline)
Action Increases cAMP in lung tissue causing bronchodilation Restores circulation and increases airway patency First line of defense in acute asthma attack or anaphylaxis, given subQ/IM Side effects Palpitations, dizziness Nervousness, tremors Tachycardia, dysrhythmias, hypertension

Nursing Implications

Teach patient correct technique for MDI/inhaler use If pt. uses inhaler: have patient return demonstration Auscultate breath sounds prior and post administration. Monitor pulse oximetry Take vital signs: pre/post Assess mental status Check for hand tremors Have emergency equipment in room:

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Bronchodilator: Nursing Implications

Assess for chest pain. Monitor peak expiratory flow rates: PEFR Compare HR & BP within 15 min. post administration. Report severe tachycardia, rapid rise in BP or chest pain stat to prescriber Administering 2 or more inhalation drugs for asthma at same time, give BRONCHODILATOR FIRST and wait 5 minutes before giving second and third drugs.

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Bronchodilator: Nursing Implications

Teach pt. to carry short-acting beta agonists [Rescue] drugs at all times. Instruct patient to ensure inhaler levels by place in water. Instruct to take LABA as prescribed even when symptoms are not present: prevent attack not stop an attack that has already started.

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Bronchodilator: Nursing Implications

Patients with hand-lung coordination: use space w/one way valve Instruct pt. if 2 puffs are needed: 1-2 minutes should lapse between puffs. Warn pt. regarding exceeding recommended dosages Long-acting beta-2 [formoterol & salmeterol] should be taken on a fixedscheduled NOT PRN. Oral beta-2: take on fixed schedule NOT PRN Instruct pt. not to crush, chew.

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Bronchodilator: Nursing Implications

Teach pt. w/chronic asthma to monitor & record PEF, symptom frequency, symptom intensity, nighttime awakenings, impact on normal activity and SABA use. Instruct pt. to report chest pains Instruct pt. to rinse mouth after use of inhalers. Instruct pt. to avoid exposure to precipitating events. Instruct to maintain healthy living

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Methylxanthine Bronchodilators
Derivatives of xanthine Caffeine: Prototype Given systemically rather than by inhaler Most prominent actions of drug:

CNS excitation/stimulation Bronchodilation Other actions: cardiac stimulation, vasodilation, diuresis

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Methylxanthine Bronchodilators
Plant

alkaloids: caffeine, theobromine, and theophylline Synthetic xanthines: aminophylline and dyphilline Theophylline (Theo-Dur) Only used as a bronchodilator

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Drug Profile
Theophylline [Theo-Dur] Use: asthma; COPD [Maintenance] Route: PO Narrow therapeutic index: serum levels must be monitored. Therapeutic levels: 10-20 mcg/mL. Toxicity: 1st sign of toxicity: STOP drug Antidote: activated charcoal w/a cathartic.

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Mechanism of Action
Increases

the amount of cAMP in cells = increased respiratory smooth muscle cells = BRONCHODILATION.

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Adverse Effects
Most dangerous: cardiac & CNS stimulation Common: N/V, anorexia, GERD Cardiac overstimulation:

INCREASED force of contraction [positive inotropy] increases CO & blood flow to kidneys [DIURESIS]; INCREASED HR [positive chronotropy]

CNS overstimulation:Vasoconstriction
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Contraindications/Interactions
Uncontrolled cardiac dysrhythmias Seizures, hyperthyroidism, PUD Interactions

Caffeine & other sympathomimetics: additive effect Rifamin: decreased drug levels: enhances metabolism; higher dosage needed Herbal: St. Johns Wort [Hypericum perforatum] Cigarette smoking Foods: charcoal-broiled, high protein, low 32 CHO: reduce serum levels

Nursing Implications

Thorough cardiac, respiratory & neuro assessment Monitor renal & LFTs Educate regarding cigarette smoking. Obtain baseline urinary patterns and FEV1, frequency of attacks Thorough dietary assessment Monitor serum drug levels Instruct patient to take as prescribed Instruct patient NOT to crush, chew time release caps
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Nursing Implications

Do not double dose if dose is missed. Caution against caffeine consumption or caffeine containing products: coffee, soft drinks-colas, chocolate, cocoa, tea. Instruct patient to report to physician: Palpitations Weakness Convulsions Nausea Dizziness Vomiting Chest pain
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Leukotriene Receptor Antagonists LTRAs]

Leukotriene

Family of molecules produced as a result of chemical reactions.

In asthma: inflammation, bronchoconstriction & mucus production leading to coughing, wheezing & SOB. LTRAs

Prevent leukotrienes from attaching to receptors located on circulating immune cells [i.e. lymphocytes in blood] as well as local immune cells within lungs [alveolar macrophages] = alleviation of asthma symptoms in lungs thereby reducing inflammation.

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Drug Profiles
2 subclasses First subclass: Zileuton [Ayflo] Second subclass: Montelukast [Singular] Zafirlukast [Accolate]

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Drug Profile
Montelukast [Singular] Approved for use in children > 2 yr. age Route: PO only: tabs [10 mg], chewable[4, 5 mg], oral granules [4 mg/packet] Dose: Adult & child >15 yr: 10 mg daily PM Herbals: Guarana, black, green tea [stimulation] Precaution: ASA sensitivity [do not take NSAIDS]

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Mechanism of Action

Drug effects: primarily lungs Prevents smooth muscle contraction of bronchial airways Decreases mucus secretion Reduce vascular permeability [reduces edema] Reduce inflammation

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Indications
Prophylaxis

and chronic treatment of asthma in adults and children older than age 12 NOT meant for management of acute asthmatic attacks Allergic rhinitis

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Adverse Effects

Zileuton

Headache, dyspepsia, nausea, dizziness, insomnia, abdominal pain, liver dysfunction Headache, nausea, diarrhea, liver dysfunction

Zafirlukast

Montelukast has fewer adverse effects

Phenobarbital: decreases drug concentration Rifampin: decrease singular levels Mood/behavior changes [serious]
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Nursing Implications

Ensure that pt. is using drug for chronic management of asthma, NOT acute asthma. Teach pt. the purpose of therapy. Teach pt. that improvement should be seen in 1 week. Instruct pt. to take dose in PM daily. Granule formulation: directly into mouth or mix w/a spoonful of soft food [carrots, applesauce, ice cream, rice]: 12-23 mos. Do not open granules packet until ready to use; mix whole dose; give within 15 minutes.
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Nursing Implications
Monitor baseline LFTs & periodic. Note type of asthma attack. Emphasize to pt. that these drugs are indicated for prevention, NOT treatment, of acute asthmatic attacks. Advise pt. to check with provider prior to taking OTC or prescribed meds. Teach pt. to take meds every PM on a continuous schedule, even if symptoms improve.

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Corticosteroids
Glucocorticoid steroids Synthetics used in drug therapy: inhalation, PO, IV Anti-inflammatory properties

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Inhaled Corticosteroids

Methylprednisolone (Solu-medrol]: IV; Medrol: PO Prednisone (oral) Inhaled

beclomethasone dipropionate (QVAR, Beclovent, Vanceril) Budesonide (Pulmicort) triamcinolone acetonide (Azmacort) dexamethasone sodium phosphate (Decadron Phosphate Respihaler) fluticasone (Flovent, Flonase) Flunisolide (AerobBid) Mometasone furoate [Asmanex]
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Mechanism of Action

Suppress inflammation Reduce bronchial hyperreactivity Decrease airway mucus production

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Indications
Bronchospastic disorders to control inflammation Prophylaxis of chronic asthma. Used concurrently w/bronchodilators, primarily beta-2 adrenergic agonists [rescue drugs]. Acute asthma episodes: systemic use

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Interactions
Antidiabetics drugs: hyperglycemia Immunosuppressants cyslosporine & tacrolimus: elevated levels from steroid use Phenytoin [Dilantin], phenobarbital, rifampin: enhance drug Concurrent use of potassiumdepleting diuretics [HCTZ, furosemide [Lasix]]

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Adverse Effects

Oropharyngeal candidiasis & dysphonia: most common. Pharyngeal irritation, coughing, dry mouth Adrenal suppression [long-term] PO use Bone loss [osteoporosis]: brittle bones Slow growth [children/adults] Hyperglycemia PUD Increased susceptibility to infection
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Adverse Effects
Fluid & electrolyte Moon face Insomnia, nervousness, seizures Brittle skin, fragile, onion-like Increased risk glaucoma and cataracts: long term use

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Monoclonal Antibody Antiasthmatic

Omalizumab [Xolair] Action: Antagonism of IgE Use: 2nd line for allergy-related asthma only Route: Parenteral only: SubQ Adverse effects: anaphylaxis [potential]

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Mast Cell Stabilizers

Cromolyn [Intal]
Alternative therapy to inhaled GCS therapy. Prophylaxis of asthma; not useful for aborting attack. Exercise-induced bronchospasm [acute] Allergic rhinitis [intranasal]

Route: Inhalation [MDI or nebulizer] Action: suppresses inflammation; NOT a bronchodilator Nedocrimil [Tildate]

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Combination Bronchodilator & Anti-inflammatory

Prevention therapy for asthma & COPD Fluticasone & salmeterol [Advair Diskus] budesonide & formorterol [Symbicort]

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Mucolytics
Improve airflow by reducing thickness of mucus in airways. Guaifenesin {Mucinex}: systemic mucolytic: PO Major mucolytic for COPD: acetylcysteine {Mucomyst]: thinner, less sticky mucus Route: nebulizer face mask, PO Unpleasant odor: _______________________ N/V: from drug odor

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