Ppt chapter 35

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Chapter 35

Drugs Affecting the Lower Respiratory System

Chapter 35

Drugs Affecting the Lower Respiratory System


Physiology 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 TractLower Respiratory Tract


Pathophysiology 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.)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 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 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.)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 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 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.)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 InterventionsAcetylcysteine: 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 EvaluationAcetylcysteine: 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.


QuestionQuestion

• Acetylcysteine is administered by

– A. Inhalation

– B. SC

– C. Oral

– D. IV


AnswerAnswer

• A. Inhalation

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


Bronchodilators 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 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.)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 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 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 InterventionsAlbuterol: 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 EvaluationAlbuterol: Teaching, Assessment, and Evaluation

• Patient and family education

– 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.


QuestionQuestion

• Albuterol is given for acute exacerbation of CAL or asthma.

– A. True

– B. False


AnswerAnswer

• A. True

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


Respiratory Anticholinergic Agents 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 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.)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 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 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 InterventionsIpratropium 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 EvaluationIpratropium 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.


QuestionQuestion

• Patients with hypersensitivity to ________ cannot use ipratropium bromide.

– A. Dairy

– B. Eggs

– C. Wheat

– D. Legumes


AnswerAnswer

– D. Legumes

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


Xanthine Derivatives 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 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.)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 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 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 InterventionsTheophylline: 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 EvaluationTheophylline: 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.


QuestionQuestion

• 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


AnswerAnswer

• 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 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 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.)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 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 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 InterventionsFlunisolide: 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 EvaluationFlunisolide: 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.


QuestionQuestion

• Patients using flunisolide are at a high risk for developing

– A. Oral bacterial infection

– B. Oral viral infection

– C. Oral fungal infection


AnswerAnswer

• C. Oral fungal infection

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


Mast Cell Stabilizers 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 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.)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 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 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 InterventionsCromolyn 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 EvaluationCromolyn 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.


QuestionQuestion

• 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


AnswerAnswer

• 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 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 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.)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 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 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 InterventionsZafirlukast: 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 EvaluationZafirlukast: 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.


QuestionQuestion

• Zafirlukast is used for

– A. Prophylaxis

– B. Acute attack

– C. Infection

– D. All of the above


AnswerAnswer

• A. Prophylaxis

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

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Ppt chapter 35