Respiratory Update for SCC Nursing Faculty

Respiratory Update for SCC Nursing FacultyRespiratory Medications Refresher and Update on Recent ChangesPresented by Cynthia FoutsJune, 2012Learning Objectives:At the conclusion of viewing this presentation, the learner will be able toclassify respiratory medications.explain the reason for MDI changes which have occurred over the past decade.demonstrate the procedure for administration of both MDI and DPI medications.list recently discontinued respiratory medications

As of June, 2012, there are 93 FDA approved drugs for use to treat respiratory ailments. This presentation will cover 12 medications which have been approved in the last decade. It will also discuss new delivery methods for previously approved medications and medications used in different therapeutic applications.Respiratory Medication ClassificationsAntihistaminesAntitussivesBronchodilatorsInhaled CorticosteroidsDecongestantsMucolyticsNon-steroidal antiasthma agents

There are other respiratory medications but most fall within these categories.Antihistaminesblock histamine; decrease inflammation and reduce secretions2nd generation cause less drowsiness than the 1st generation antihistaminesalso have anti-cholinergic effect cause dry mouth

Antitussivessuppress the cough reflex at the medulla oblongata; narcotics may depress respiratory drivebenzonatate narcoticbutamirate citrate non-narcoticcodeine narcoticdextromethorphan non-narcotichydrocodone narcotic

important - ensure the patient dont suffer from pooling of secretions if cough is suppressed.Bronchodilatorsdilate the airways by releasing constriction of the muscles surrounding them3 different classificationsXanthinesSympathomimetics (Adrenergic)Parasympatholytic (Anticholinergics)

Bronchodilator - Xanthinesstimulate the CNS thus stimulating respiration, dilating coronary and pulmonary arteries, and act as a diuretic.Theophylline, Aminophylline, Caffeine2nd or 3rd line agent in treating COPD and asthmauseful in treating Apnea of PrematurityBronchodilator - Sympathomimeticsmimic the effect of the sympathetic nervous system to dilate the bronchi and increase the rate and depth of respirationmost are beta2 specific increase concentration of cellular cAMPshort-acting and long-acting beta agonists (SABA, LABA)albuterol, bitolterol, salbutamol, terbutaline, racemic ephiniphrine, levalbuterol

Bronchodilator - Anticholinergicsblocks effects of acetylcholine at the cholinergic receptors on bronchial smooth muscleIpratroprium bromide and tiotropium bromidespecifically approved for COPD but may be used in treatment of asthma also.studies have shown additive effect when used in conjunction with beta agonists.

Inhaled Corticosteroidsdecrease inflammatory response within the airwayswhen inhaled, systemic side effects are diminishedlong-term use in treatment of COPD and Asthmaalways rinse the mouth after inhalation of a steroid to reduce incidence of oral thrushFlunisolide, fluticasone, budesonide, mometasone, ciclesonide

NOT FOR EMERGENCY USE DO NOT USE DURING AN ACUTE ASTHMA ATTACK.Decongestantsdecrease blood flow to upper respiratory tract and decrease excessive production of secretionsespecially useful in allergic rhinitismay be given orally or by nasal spray

MucolyticsAcetylcysteine decreases the viscosity of sputum by breaking the disulfide bonds which connect the mucin proteins.Not shown to really be helpful in treating lung diseasesmay be given orally as an antioxidant antidote to reduce liver injury with acetaminophen overdose

MucolyticsDornase alpha a peptide mucolytic which reduces extracellular DNA and F0actin polymers indicated in treatment of cystic fibrosiscurrently being used in treatment of other pulmonary diseases although no efficacy has yet been shown

Non-steroidal Anti-asthma Agentsanti-inflammatory effect through mechanism different from corticosteroidsstop the inflammatory processmast cell stabilizer cromolyn sodiumantileukotrienes accolate, singuair, zyflormonoclonal antibodies - xolairprophylactic management (control) of mild persistent asthma

The Montreal Protocol is an international treaty intended to eliminate the use of substances that contribute to destroying the ozone layer, including CFCs (chlorofluocarbons).

The most commonly used inhalers were changed over to the new HFA propellant or remade as dry powder inhalers (DPI).

In switching to the new HFA format, it was discovered that dose delivery is actually enhanced with delivery by HFA as opposed to CFC a win-win situation!

Why are MDIs being changed?Comparison of dose delivery between CFC inhalers, HFA inhalers, and DPIs.

The following is a list of inhalers to be discontinued along with the corresponding date

nedocromil , June 14, 2010 metaproterenol , June 14, 2010triamcinolone , December 31, 2010cromolyn , December 31, 2010 (available as nebulized solution)flunisolide , June 30, 2011combivent, December 31, 2013 (replaced with Combivent Respimat)pirbuterol , December 31, 2013Now for a look at the new respiratory medications introduced within the past decade.

Alvesco (ciclesonide)

Approved January, 2008Prophylactic maintenance treatment of asthmaProdrug delivered via metered dose inhaler (MDI)12 time greater affinity for glucocorticoid receptors than dexamethasone.80 mcg or 160 mcg

Arcapta (indacaterol maleate inhalation powderapproved July, 2011long-acting beta2-adrenergic agonist (LABA)once daily inhalation of one 75 mg. capsulecorrect administration - dry powder inhaler taken via the neohaler using the same technique as the spiriva handihaler.

Brovana (arformoterol tartrate)approved October, 2006selective beta2-adrenergic bronchodilatorlong-term twice-daily maintenance therapy for COPD156 mcg administered twice a day by nebulizer

Daliresp (roflumilast)approved February, 2011selective phosphodiesterate 4 (PDE4) inhibitorreduces release of inflammation mediatorsuseful in treatment of COPD500 mcg tablet taken orally daily, with or without food

approved June, 2010for treatment of asthmacombination therapy of corticosteroid plus LABADosage dependent on previous therapy100 mcg/5 mcg up to 800 mcg/20 mcg BID by inhalation from MDIDulera (mometasone furoate + formoterol fumarate dihydrate)

Dymista (azelastine hydrochloride and fluticasone proprionate)approved May, 2012treatment for seasonal allergic rhinitiscombination therapy of antihistamine and corticosteroidsprayed suspension for intranasal administrationone spray per nostril twice dailyprime spray prior to initial use and if not used for 14 days.

Patanase (olopatadine hydrochloride)approved April, 2008treatment of seasonal allergic rhinitisantihistaminemetered-dose manual spray pump for intranasal administrationtwo sprays per nostril twice dailyprime prior to initial use and if not used for more than 7 days

Pulmozyme (dornase alfa)approved March, 1998mucolyticAlthough this drug was approved prior to 10 years ago, it has seen an increase in usage lately as a mucolytic for COPD patients.Efficacy has not been shown in any trials for COPD therapy

Qnasl (beclomethasone dipropionate)approved March, 2012treatment of seasonal and perennial allergic rhinitisanti-inflammatory steroidnon-aqueous nasal spray solution for intranasal inhalation80 mcg/spray administered as two sprays in each nostril once daily (total of 320 mcg/day)

Spiriva (tiotropium bromide)approved February, 2004treatment of bronchospasm associated with COPDanticholinergic18 mcg supplied in a gelatin capsule administered via the HandiHaler; one capsule dailyhttp://www.youtube.com/watch?v=bXHHFmZ_DRI&feature=related

2.5 mcg supplied in the Respimat inhaler; 2 puffs daily used with caution in patients with known cardiac rhythm disordershttp://www.youtube.com/watch?v=cIYKXuIWGfA&feature=relatedSpiriva (tiotropium bromide)

Xolair (omalizumab)approved June, 2003treatment of moderate to severe persistent asthmabinds to human immunoglobulin E (IgE) which is responsible for release of mediators of the allergic responsepowder for reconstitution into solution for subcutaneous injection150 to 375 mg SC every 2 or 4 wksdose and frequency determined by serum total IgE level.limit injection site to not more than 150 mg.

Zemaira (alpha-1-proteinase inhibitor)approved July 2003treatment of alpha-1-proteinase inhibitor (A1-PI) deficiency emphysemaintravenous therapychronic augmentation and maintenance of A1-PI deficiency and clinical evidence of emphysema

Some old favorites take on a different look!Combivent Respimat

approved March, 2012Combination of Albuterol and Ipratropium BromideSlow-moving mistPropellant-free deliveryOnly one inhalation per dose as opposed to the old MDI which requires 2 puffs per dose

The Advair diskus is approved for treatment of both COPD and Asthma. The HFA inhaler, approved in July, 2008, is only for the treatment of Asthma.http://www.youtube.com/watch?v=_iEEVkMU1IA

HFA inhaler approved June, 2006.Serevent is approved for the treatment of both COPD and Asthma. It is NOT designed to be a rescue inhaler used to treat an acute asthma attack.BibliographyBoehringer Ingelheim receives FDA approval for COMBIVENT RESPIMAT to treat COPD. (2011). Medical News. Retrieved from: http://news-medical.net/news/20111010/Boehringer-Ingelheim-rece-ves-FDA-apaproval-for-COMBIVENT-RESPIMAT-to-treat-COPD.aspxGardenhire, D. (2012). Raus Respiratory Care Pharmacology, 8th Ed., St. Louis: Elsevier Mosby .Pinoy nurze. (2008). Drugs Affecting the Respiratory System. Retrieved from: http://www.slideshare.net/pinoynurze2/pharmacology-respiratory-drugs-380509Reinventing Metered Dose Inhalers: From Poorly Efficient CFC MDIs to Highly Efficient HFA MDIs. (2003). Drug Development and Delivery (31). Retrieved from http://www.drugdeliverytech.com/ME2/dirmod.asp?sid=&nm=&type=Publishing&mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id=53E82363413A44F6AD01FDFF8D242DFERespiratory Drugs (2012) MediLexicon. Retrieved from: http://medilexicon.com/drugs-list/respiratory.php

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