drugs that affect the respiratory system for nurse (with copd)

8/4/2019 Drugs That Affect the Respiratory System for Nurse (WITH COPD)

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Drugs Acting on theRespiratory System


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Introduction

The respiratory system is subject tomany disorders that interfere withrespiration and other lung functions,

including Respiratory tract infections Allergic disorders Inflammatory disorders

Conditions that obstruct airflow (e.g.asthma and chronic obstructivepulmonary disease, COPD)


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Introduction (Contd)

Drugs that act on the respiratorysystem include Bronchodilators Corticosteroids Cromoglycates Leukotriene receptor antagonists Antihistamines Cough preparations Nasal decongestants


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Drugs acting on the respiratory system,especially for asthma, can be

administered by inhalation, theadvantages are:

Enhance therapeutic effects

Minimize systemic effects

Rapid relief of acute attacks



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Asthma is a chronic inflammatory disorder of theairways in which many cells and cellular elements

play a role, in particular, mast cells, eosinophils, Tlymphocytes, macrophages, neutrophils, andepithelial cells. In susceptible individuals, thisinflammation causes recurrent episodes of

wheezing, breathlessness, chest tightness, andcoughing, particularly at night or in the earlymorning. These episodes are usually associatedwith widespread but variable airflow obstructionthat is often reversible either spontaneously or withtreatment. The inflammation also causes anassociated increase in the existing bronchialhyperresponsiveness to a variety of stimuli.


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The condition of a patients asthma may change depending on the

environment, activities, and other factors. When the patient is well,monitoring and treatment are still needed to maintain control.


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There are various types of inhalationdevices:

Metered-dose inhalers (MDIs)Pressurized devices that deliver a measured

dose of drug with each activation

With CFC or non-CFC propellant

Hand-mouth coordination is required



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Spacers:

Use with MDIs

Increase delivery of drug to the lungs &

decrease deposition of drug on theoropharyngeal mucosa

Especially important for inhaledcorticosteroids



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Dry-powder inhalers (DPIs)

Include Turbuhalers & Accuhalers

Drugs are in the form of dry, micronizedpowder

No propellant is employed

Breath activated, much easier to use



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Nebulizers

Small machine to convert a drug solution intomist

Droplets in the mist are much finer than thoseproduced by inhalers

Through face mask or mouth piece heldbetween the teeth

Take several minutes to deliver the sameamount of drug contained in 1 puff from aninhaler



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Bronchodilators

Drugs used to relieve bronchospasmsassociated with respiratory disorders

Includes: Adrenoceptor agonists

Selective 2-agonists & other adrenoceptoragonists

Antimuscarinic bronchodilators Xanthine derivatives


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Bronchodilators (Contd)

Adrenoceptor agonists

(i) Selective beta2 agonists

Stimulate beta2 receptors in smooth muscleof the lung, promoting bronchodilation, andthereby relieving bronchospasms

They are divided into short-acting & longacting types


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Drug Formulation Dosage

Adult Child

Salbutamol Oral tablet (C.R) 8 mg twice daily 4 mg twice dailyInhaler (MDI), 100mcg/dose 100-200mcg up to three to

four times dailySame as adult

Syrup, 2mg/5ml 4 mg three to four timesdaily

1-2 mg three to four timesdaily (2 yr)

Terbutaline Oral tablet (S.R) 5-7.5 mg two times daily -

Inhaler 500mg / dose( Turbuhaler)

500 mcg up to four timesdaily

-

Inhaler 250mg / dose (MDI) 250-500mcg up to 3-4 timesdaily

Same as adult

Short-acting -2 agonists


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Long-acting -2 agonists


Adult Child

Formoterol Inhaler 4.5mcg / dose(Turbuhaer)

4.5-9 mcg once or twicedaily

Same as adult

Inhaler 9mcg / dose(Turbuhaer)

Salmeterol Inhaler 25mcg / dose(MDI)

50-100 mcg twice daily Same as adult

50 mcg / dose (Accuhaler) 50 mcg twice Same as adult


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Adverse effects

Tachycardia andpalpitations

Headache

Tremor


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(ii) Other adrenoceptor agonists

Less suitable & less safe for use asbronchodilators because they are more likely

to cause arrhythmias & other side effects

Ephedrine

Adults: 15-60 mg tid po

Child: 7.5-30 mg tid po

Adrenaline (epinephrine) injection is used inthe emergency treatment of acute allergicand anaphylactic reactions


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Nursing Alerts

When 2 or more puffs are needed, inform the patientthat at least 1 minute should be allowed between puffs

Inform the patient that salmeterol and formoterol, andoral -2 agonists should be taken on a fixed schedule,not on a prn basis

Instruct the patient to report chest pain and changes inheart rhythm or rate, because -2 agonists can cause

cardiac stimulationContact physician if symptoms such as nervousness,

insomnia, restlessness and tremor become severe


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Antimuscarinic bronchodilators Blocks the action of acetylcholine in

bronchial smooth muscle, this reducesintracellular GMP, a bronchoconstrictivesubstance

Used for maintenance therapy of

bronchoconstriction associated withchronic bronchitis & emphysema


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Adult Child

Ipratropium Inhaler 20 mcg / dose(MDI)

20-80 mcg three to fourtimes a day

20-40 mcg three to fourtimes a day (6yrs)

Tiotropium Inhaler 18 mcg /dose 18 mcg daily Not recommended inchildren and adolescents


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Adverse effects:

Dry mouth

Nausea Constipation

Headache



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Xanthine Derivatives

Main xanthine used clinically istheophylline

Theophylline is a bronchodilator whichrelaxes smooth muscle of the bronchi, it isused for reversible airway obstruction

One proposed mechanism of action is that

it acts by inhibiting phosphodiesterase,thereby increasing cAMP, leading tobronchodialtion


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Bronchodilators (Contd)Drug Formulation Dosage

Adult Child

Theophylline Tablet 200 / 300 mg(S.R.)

200 300 mg twice daily 10 mg / kg ((2yrs) twicedaily

Capsule 50 / 100 mg

(Slow release)

7-12 mg/ kg / day in two divided

doses

10-16 mg / kg / day in two

divided doses (916yrs)

13-20 mg / kg / day in twodivided doses (30 months 8yrs)

Syrup 80 mg / 15 ml 25 ml q6h 1 ml / kg (Max 25 ml) q6h(2yrs)

Aminophylline Injection 25 mg / ml

10 ml

500 mcg / kg / hr IV infusion,adjust when necessary

1 mg / kg /hr (6 months 9years)

800 mcg / kg /hr (10 16 yrs)

IV infusion, adjust whennecessary


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Adverse effects:

Toxicity is related to theophyline levels(usually 5-15 g/ml)

20-25 g/ml : Nausea, vomiting, diarrhea,insomnia, restlessness

>30 g/ml : Serious adverse effects includingdysrhythmias, convulsions, cardiovascular

collapse which may result in death


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Nursing alerts:

Plasma theophylline levels should be monitoredto keep it in the therapeutic range, usually 5-15

g/ml. Dosage should be adjusted to keeptheophylline levels below 20 g/ml

If patients miss a dose, the following dose shouldnot be doubled


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Nursing alerts (Contd):

Instruct the patient that sustained-release

formulations should be swallowed intactCaution patients in consuming caffeine

containing-beverages and other sources ofcaffeine. Caffeine can intensify the adverseeffects and decrease the metabolism of

theophylline



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Corticosteroids

Used for prophylaxis of chronic asthma

Suppressing inflammation

Decrease synthesis & release of inflammatory

mediators

Decrease infiltration & activity of inflammatory cells

Decrease edema of the airway mucosa

Decrease airway mucus production

Increase the number of bronchial beta2receptors & their responsiveness to beta2agonists


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Corticosteroids (Contd)


Adult Child

Beclomethasone Inhaler 50 mcg / dose

(MDI)

200 mcg twice daily /100mcg three to fourstimes daily

Up to 800 mcg daily

50 100 mcg two to fourtimes daily

Inhaler 250 mcg / dose

(MDI)

500 mcg twice daily / 250mcg four times daily

Not recommended


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Corticosteroids (Contd)Drug (Contd) Formulation Dosage

Adult Child

Budesonide Inhaler 50 mcg / dose(MDI)

200 mcg twice daily

Up to 1.6 mg daily

50 400 mcg twicedaily

Up to 800 mcg daily

Inhaler 200mcg / dose(MDI)

Inhaler 100 mcg / dose(Turbuhaler)

200-800 mcg once dailyin evening

Up to 1.6 mg daily intwo divided doses

200-800 mcg daily intwo divided doses /200-400 mcg oncedaily in evening

(


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Corticosteroids (Contd)Drug (Contd) Formulation Dosage

Adult Child

Fluticasone Inhaler 25mcg / dose (MDI) 100 1000 mcgtwice daily

50-100 mcg twice daily(4-16 yrs)

Inhaler 50 mcg / dose (MDI)



Inhaler 50 mcg / dose (Accuhaler)



Acute attacks of asthma should be treated with short coursesof oral corticosteroids, starting with a high dose for a few days


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Adverse effects

Inhaled corticosteroids:

Candidiasis of the mouth or throatHoarseness

Can slow growth in children

Adrenal suppression may occur in long-term,high dose therapy

Increases the risk of cataracts


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Nursing alerts

Rinse mouth with water without swallowing

after administration to reduce the risk ofcandidiasis

If taking bronchodilators by inhalation, usebronchodilators several minutes before the

corticosteroid to enhance application of thecorticosteroid into the bronchial tract


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Combination Products

May be appropriate for patients stabilised onindividual components in the same proportion

Muscarinic antagonist+2 agonist

Combivent (20mcg Ipratropium & 100mcgsalbutamol /dose, MDI)

Corticosteroid+2 agonist

Symbicort (160mcg Budesonide+4.5mcg

Formoterol / dose, Turbuhaler)

Seretide (Salmeterol+Fluticasone: MDi in Lite,Medium, Forte preparation & Accuhaler)


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Cromoglycates

Stabilise mast cells & prevent therelease of bronchoconstrictive &

inflammatory substances when mastcells are confronted with allergens &other stimuli

Only for prophylaxis of acute asthma

attacks


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Cromoglycates (Contd)


Adult Child

Cromoglycate Na Inhaler (1 mg

& 5mg/dose)

10 mg four times daily, may be

increased to six to eight timesdaily

Same as adult

Nebulisersolution 10 mg/ ml 2 ml

20 mg four times daily, may beincreased six times daily

Same as adult

Nedocromil

Sodium

Inhaler 2 mg /

dose (MDI)

4 mg two to four times daily Sames as adult (>6

yrs)


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Adverse effects Nursing Alerts

Transient Bronchospasm A selective 2 agonist such as

salbutamol or terbutaline maybe inhaled a few minutesbeforehand

Others: coughing, throat irritation


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Nursing Alerts (Contd)

Cromoglycates are for long-term

prophylaxis, patients should administer ona regular schedule & the full therapeuticeffects may take several weeks to develop

They are contraindicated in patients who

are hypersensitive to the drugs



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Leukotriene receptor

antagonists Act by suppressing the effects of

leukotrienes, compounds that promote

bronchoconstriction as well aseosinophil infiltration, mucus productions,& airway edema

Help to prevent acute asthma attacks

induced by allergens & other stimuli Indicated for long-term treatment of

asthma


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Dosage:

Montelukast (5 & 10 mg tablets)

Adult: 10 mg daily at bedtimeChild:

(2-5yrs) 4 mg daily at bedtime

(6-14yrs) 5 mg daily at bedtime


antagonists (Contd)


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Adverse effects:

GI disturbances

Hypersensitivity reactions Restlessness & headache

Upper respiratory tract infection

Manufacturer advises to avoid these drugs

in pregnancy & breast-feeding unlessessential


antagonists (Contd)


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Management of Chronic Asthma foradults & schoolchildren above 5yrs

Step 1: Occasional relief short-acting

beta2 agonist

Step 2: Add regular preventer therapy

Standard-dose inhaled corticosteroid


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(Contd)

Step 3: Add long-acting inhaled beta2 agonist;

dose of inhaled corticosteroid may also be increased

Step 4: Add high dose of inhaled corticosteroids


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(Contd)

Step 5: Add regular oral corticosteroid

E.g. prednisolone


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Stepping down:

Review treatment every 3 months

If symptoms controlled, may initiatestepwise reduction

Lowest possible dose oral corticosteroid

Gradual reduction of dose of inhaledcorticosteroid to the lowest dose whichcontrols asthma


(Contd)


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Antihistamines

H1 receptor antagonists

Inhibit smooth muscle constriction in bloodvessels & respiratory & GI tracts

Decrease capillary permeability

Decrease salivation & tear formation

Used for variety of allergic disorders to

prevent or reverse target organinflammation


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All antihistamines are of potential valuein the treatment of nasal allergies,

particularly seasonal allergic rhinitis (hayfever)

Reduce rhinorrhoea & sneezing but areusually less effective for nasal

congestion Are also used topically in the eye, in the

nose, & on the skin

Antihistamines (Contd)


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First-generation H1 receptor antagonists

Non-selective/sedating

Bind to both central & peripheral H1receptors

Usually cause CNS depression(drowsiness, sedation) but may causeCNS stimulation (anxiety, agitation),

especially in children Also have substantial anticholinergic

effects



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Drug Dosage

Adult Child

Chorpheniramine(4 mg tablet,2mg/ml Elixir &

expectorant)

4 mg q4-6hr, max: 24 mgdaily

1-2yrs: 1 mg twice daily

2-12yrs: 1- 2 mg q4-6h, Max:12 mg daily

Hydroxyzine (25mg tablet)

25 mg at night; 25mg three tofour times daily whennecessary

6 months-6yrs: 5-15 mg daily; 50 mgdaily in divided dose if needed

>6yrs: 15-25 mg daily; 50-100 mg daily individed dose if needed

Diphendramine (10mg/5ml Elixir)

25-50 mg q4-6h 6.25-25 mg q4-8 hr ( >1 yr)


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Drug (Contd) Dosage

Adult Child

Promethazine (10 &

25 mg tablets,5mg/5ml Elixir)

25 mg at night; 25 mg twice daily

if needed

2-10yrs: 5-25 mg daily in 1 to 2

divided dose

Azatadine (1 mgtablet)

1 mg twice daily 1-12 yrs: 0.25-1 mg twice daily


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Adverse effects:

Sedation

Dry mouth

Blurred vision

GI disturbances

Headache

Urinary retention Hydroxyzine is not recommended for

pregnancy & breast-feeding


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Second-generation H1 receptor antagonists

Selective/non-sedating

Cause less CNS depression because they areselective for peripheral H1 receptors & do notcross blood-brain barrier

Longer-acting compared to first-generation

antihistamines



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Drug Dosage

Adult Child

Acrivastine(Semprex)

8 mg three times daily Not recommended

Cetirizine(Zyrtec)

10 mg daily 5 mg daily / 2.5 mg twice daily (2-6 yrs)

Desloratadine(Aerius)

5 mg daily 1.25 mg daily (2-5 yrs)

2.5 mg daily (6-11yrs)

Fexofenadine(Telfast)

120-180 mg daily Not recommended

Loratadine(Clarityne)

10 mg daily` 5 mg daily (2-5 yrs)


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Adverse effects:

May cause slight sedation

Some antihistamines may interact withantifungal, e.g. ketoconazole; antibiotics,e.g. erythromycin; prokinetic drug--cisapride or grapefruit juice, leading topotentially serious ECG changes e.g.Terfenadine


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Cough preparations

There are three classes of coughpreparations:

Antitussives Expectorants

Mucolytics


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Antitussives

Drugs that suppress cough

Some act within the CNS, some actperipherally

Indicated in dry, hacking, nonproductivecough that interfere with rest & sleep

Cough preparations (Contd)


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Drug Dosage

Codeine phosphate 25mg/5ml syrup 15-30 mg three to four times daily

Pholcodine 5mg/5ml Elixir 5-10 mg three to four times daily

Dextromethorphan 10mg/5ml in PromethazineCompound Linctus

10-30 mg q4-8h

Diphenhydramine 10 mg/ 5ml 25 mg q4h, Max:150 mg daily


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Adverse effects:

Drowsiness

Respiratory depression (for opioid

antitussives)

Constipation (for opioid antitussives)

Preparations containing codeine or similaranalgesics are not generally recommendedin children & should be avoided altogetherin those under 1 year of age



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Nursing Alerts:

Observe for excessive suppression of thecough reflex (inability to cough effectivelywhen secretions are present). This is apotentially serious adverse effect becauseretained secretions may lead to lungscollapse, pneumonia, hypoxia, hypercarbia,

and respiratory failure



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Expectorants

Render the cough more productive bystimulating the flow of respiratory tractsecretions

Guaifenesin is most commonly used

Available alone & as an ingredient in many

combination cough & cold remedies



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Dosage

Guaifenesin

100-400 mg q4h po

Ammonia & Ipecacuaha Mixture

10-20 ml three to four times daily po



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Mucolytics

Reacts directly with mucus to make it morewatery. This should help make the coughmore productive



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Dosage

Acetylcysteine 100 mg two to four times daily

200 mg two to three times daily 600 mg once daily

Bromhexine 8-16 mg three times daily po

Carbocisteine 750 mg three times daily, then 1.5 g daily in

divided doses



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Sympathomimetics are used to reducenasal congestion

Stimulate alpha1-adrenergic receptors onnasal blood vessels, which causesvasoconstriction & hence shrinkage ofswollen membranes

Nasal Decongestants


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Topical administration:

Response is rapid & intense

Oral administration: Response are delayed, moderate &

prolonged

Nasal Decongestants (Contd)


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Nasal Decongestants (Contd)Drug Formulation Dosage

Adult Child

Oxymetazoline Nasal Drops 0.025% 20 ml - 2-3 drops q12h (2-5 yrs)

Nasal Spray 0.05% 15 ml 2-3 sprays q12h Same as adults forchildren >6 yrs

Phenylephrine Nasal Drops 0.5% 10 ml Several drops q2-4h -

Xylometazoline Nasal Drops 0.05% / 0.1% 2-3 drops q8-10h (0.1%) 2-3 drops q8-10h (2-12yrs) (0.05%)


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Adverse effects:

Rebound congestion develops with topicalagents when used for more than a few days

CNS stimulation (such as restlessness,irritability, anxiety and insomnia) occurs withoral sympathomimetics


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Adverse effects (Contd):

Sympathomimetics can causevasoconstriction by stimulating -1adrenergic receptors. More common withoral agents

Sympathomimetics cause CNS stimulation,and can produce effects similar toamphetamine. Hence, these drugs aresubject to abuse



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Nursing alerts:

Overuse of topical nasal decongestantscan cause rebound congestion, meaning

that the congestion can be worse with theuse of drug. To minimise this, drugtherapy should be discontinued gradually.

The use of topical agents is limited to no

more than 3 to 5 days


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Nursing alerts (Contd):

The patients blood pressure and pulse

should be assessed before a decongestantis administered

Inform the patient that nasal burning andstinging may occur with topicaldecongestants


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Intranasal Corticosteroids

Intranasal Corticosteroids

Most effective for treatment of seasonaland perennial rhinitis

Have inflammatory actions and canprevent or suppress all major symptoms ofallergic rhinitis including congestion,rhinorrhea, sneezing, nasal itching anderythema


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Intranasal Corticosteroids (Contd)


Adult Child

Beclomethasone

Dipropionate

Nasal Spray 50 mcg /

dose

1 spray in each nostril

four times dailyMax. 10 sprays / day

4-6 sprays / day

Nasal Spray 50 mcgdose (Aqueous)

2 applications intoeach nostril twice tofour times daily

Max. 400 mcg daily

Same as adult (>6 yrs)

Not recommended inchildren


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Drug (Contd) Formulation Dosage

Adult Child

Budesonide Nasal Spray 50 mcg /dose (Aqueous)

1-2 sprays into eachnostril twice daily; after2-3days: 1 spray intoeach nostril twice daily

Not recommended forage 12 yrs or below

Turbuhaler 100mcg /dose

400 mcg in the morninggiven as 2 applications

into each nostril; thenreduce to the smallestamount necessary

-


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Drug (Contd) Formulation Dosage

Adult Child

Fluticasone Nasal Spray 50 mcg/ dose (Aqueous)

2 sprays into eachnostril in the morning

Max: 8 sprays/day

1 spray into eachnostril in the morning(4-11yrs)

Max: 4 sprays/day

Mometasone Nasal Spray 50 mcg/ dose

2 sprays in eachnostril once daily;1spray in each nostrilas maintenance

Max: 8 sprays/day

1 spray in eachnostril once daily

(3-11yrs)


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Adverse effects:

Mild

Most common effects are drying of nasalmucosa & sensations of burning or itching



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Chronic Obstructive PulmonaryDisease (COPD)

Umbrella term for various conditionscharacterized by limitation of airflow that is notfully reversible

Chronic airflow limitation caused by a mixture ofsmall airway disease and parenchymaldestruction

Airflow limitation is often progressive

Associated with an abnormal inflammatory

response of lungs to noxious substances PREVENTABLE and TREATABLE disease


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Relationship between COPD andemphysema/chronic bronchitis

Emphysema

Destruction of the gas exchanging surfaces of the lung(alveoli)

Pathological term that describes only one of several

structural abnormalities present in patients with COPD Chronic bronchitis

Presence of cough and sputum production for at least 3months in each of two consecutive years

Remains a clinically and epidemiologically useful term,but does not reflect the major impact of airflow limitationon morbidity and mortality in COPD patients

The emphasis on these conditions are not included in thedefinition of COPD in current relevant clinical guidelines


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Mechanisms of COPD

Ref: Global Initiative for Chronic Obstructive Lung Disease (GOLD), National Heart, Lung, and Blood Institute (U.S.) - FederalGovernment Agency [U.S.] World Health Organization - International Agency. 2001 (revised 2006).


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Risk factors

Genes Exposure to particles

Tobacco smoke

Occupational dusts, organic and inorganic

Indoor air pollution from heating and cooking with biomass in

poorly vented dwellings Outdoor air pollution

Lung Growth and Development Oxidative stress Gender (appears to be related to cigarette use?) Respiratory infections

Socioeconomic status Nutrition Comorbidities (e.g. asthma)


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GOLD report COPD StagingSystem

Stage /Severity

PostbronchodilatorFEV1/ FVC and FEV1 pred.

Characteristics

Stage I:Mild

FEV1/FVC < 0.70

FEV1 80% predicted

chronic cough and sputum production may bepresent, but not always

Stage II:Moderate

FEV1/FVC < 0.70

50% FEV1 < 80% predicted

shortness of breath typically developing onexertion and cough and sputum production

sometimes also presentStage III:Severe

FEV1/FVC < 0.70

30% FEV1 < 50% predicted

greater shortness of breath, reduced exercisecapacity, fatigue, repeated exacerbations thatalmost always have an impact on patients quality

of life

Stage IV:Very

severe

FEV1/FVC < 0.70

FEV1 < 30% predicted or FEV1

drugs that affect the respiratory system for nurse (with copd)

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