respi drugs
DESCRIPTION
TRANSCRIPT
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Drugs affecting the respiratory system
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Objectives
1. Antihistamines2. Decongestants3. Antitussives4. Expectorants5. Bronchodilators6. Beta adrenergic agonist7. Anticholinergics8. Antileukotriene agents9. Corticosteroids10. Mast cell stablizers
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Understanding the Common Cold
Most caused by viral infection
(rhinovirus or influenza virus—the “flu”)
Virus invades tissues (mucosa) of upper respiratory
tract, causing upper respiratory infection (URI)
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Treatment of the Common Cold
Involves combined use of antihistamines, nasal
decongestants, antitussives, and expectorants
Treatment is symptomatic only, not curative
Symptomatic treatment does not eliminate the
causative pathogen
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Treatment of the Common Cold (cont’d)
Difficult to identify whether cause is viral or
bacterial
Treatment is “empiric therapy,” treating the most
likely cause
Antivirals and antibiotics may be used, but a
definite viral or bacterial cause may not be easily
identified
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Antihistamines
Drugs that directly compete with histamine
for specific receptor sites
Two histamine receptors
H1 (histamine1)
H2 (histamine2)
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Antihistamines (cont’d)
H1 histamine receptor- found on smooth muscle, endothelium, and central nervous system tissue; causes vasodilation, bronchoconstriction, smooth muscle activation, and separation of endothelia cellss (responsible for hives), and pain and itching due to insect stings
H1 antagonists are commonly referred to as antihistamines Antihistamines have several properties
Antihistaminic Anticholinergic Sedative
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Antihistamines (cont’d)
H2 blockers or H2 antagonists
Used to reduce gastric acid in PUD
Examples: cimetidine, ranitidine, famotidine
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Antihistamines (cont’d)
10% to 20% of general population is sensitive to various environmental allergies
Histamine-mediated disorders Allergic rhinitis (hay fever, mould and dust allergies) Anaphylaxis Angioneurotic edema Drug fevers Insect bite reactions Urticaria (itching)
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Antihistamines: Mechanism of Action
Block action of histamine at the H1 receptor sites
Compete with histamine for binding at unoccupied
receptors
Cannot push histamine off the receptor if already
bound
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Antihistamines: Mechanism of Action (cont’d)
The binding of H1 blockers to the histamine
receptors prevents the adverse consequences of
histamine stimulation Vasodilation
Increased GI and respiratory secretions
Increased capillary permeability
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Antihistamines: Mechanism of Action (cont’d)
More effective in preventing the actions of
histamine rather than reversing them
Should be given early in treatment, before all
the histamine binds to the receptors
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Antihistamines: Indications
Management of: Nasal allergies Seasonal or perennial allergic rhinitis
(hay fever) Allergic reactions Motion sickness Sleep disorders
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Antihistamines: Indications (cont’d)
Also used to relieve symptoms associated with
the common cold
Sneezing, runny nose
Palliative treatment, not curative
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Antihistamines: Side effects
Anticholinergic (drying) effects, most common Dry mouth Difficulty urinating Constipation Changes in vision
Drowsiness Mild drowsiness to deep sleep
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Antihistamines: Two Types
Traditional
Nonsedating/peripherally acting
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Traditional Antihistamines
Older Work both peripherally and centrally Have anticholinergic effects, making them
more effective than nonsedating agents in some cases Examples: Benedryl (diphenhydramine)
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Nonsedating/Peripherally Acting Antihistamines
Developed to eliminate unwanted side effects, mainly sedation
Work peripherally to block the actions of histamine; thus, fewer CNS side effects
Longer duration of action (increases compliance)
Examples: reactine, allegra
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Antihistamines:Nursing Implications
Gather data about the condition or allergic reaction that required treatment; also assess for drug allergies
Contraindicated in the presence of acute asthma attacks and lower respiratory diseases
Use with caution in increased intraocular pressure, cardiac or renal disease, hypertension, asthma, COPD, peptic ulcer disease, BPH, or pregnancy
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Antihistamines:Nursing Implications (cont’d)
Instruct clients to report excessive sedation, confusion, or hypotension
Avoid driving or operating heavy machinery, and do not consume alcohol or other CNS depressants
Do not take these medications with other prescribed or OTC medications without checking with prescriber
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Antihistamines:Nursing Implications (cont’d)
Best tolerated when taken with meals—reduces GI upset
If dry mouth occurs, teach client to perform frequent mouth care, chew gum, or suck on hard candy to ease discomfort
Monitor for intended therapeutic effects
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Decongestants
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Nasal Congestion
Excessive nasal secretions
Inflamed and swollen nasal mucosa
Primary causes
Allergies
Upper respiratory infections (common cold)
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Decongestants: Types (cont’d)
Two dosage forms
Oral
Inhaled/topically applied to the nasal membranes
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Oral Decongestants
Prolonged decongestant effects, but delayed onset
Effect less potent than topical No rebound congestion Exclusively adrenergics Example: pseudoephedrine, Sinutab, Dristan,
Tylenol cold, Sudafed
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Topical Nasal Decongestants
Topical adrenergics Prompt onset Potent Sustained use over several days causes rebound congestion,
making the condition worse Eg:
DRISTAN* DECONGESTANT NASAL MIST (SOLUTION)
COMPOSITION:Each 1 mL of solution contains: Phenylephrine HCl 5 mg Pheniramine Maleate 2 mg
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Topical Nasal Decongestants (cont’d)
Adrenergics desoxyephedrine phenylephrine
Intranasal steroids beclomethasone dipropionate flunisolide fluticasone
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Nasal Decongestants:Mechanism of Action
Site of action: blood vessels surrounding nasal sinuses Adrenergics
Constrict small blood vessels that supply URI structures
As a result these tissues shrink, and nasal secretions in the swollen mucous membranes are better able to drain
Nasal stuffiness is relieved
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Nasal Decongestants:Mechanism of Action (cont’d)
Site of action: blood vessels surrounding nasal sinuses Nasal steroids
Anti-inflammatory effect Work to turn off the immune system cells involved in
the inflammatory response Decreased inflammation results in decreased congestion Nasal stuffiness is relieved
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Nasal Decongestants: Indications
Relief of nasal congestion associated with: Acute or chronic rhinitis
Common cold
Sinusitis
Hay fever
Other allergies
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Nasal Decongestants: Indications (cont’d)
May also be used to reduce swelling of the
nasal passage and facilitate visualization of
the nasal/pharyngeal membranes before
surgery or diagnostic procedures
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Nasal Decongestants: Side Effects
Adrenergics Steroids
Nervousness Local mucosal dryness
Insomnia and irritation
Palpitations
Tremors
(systemic effects due to adrenergic stimulation of theheart, blood vessels, and CNS)
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Nasal Decongestants:Nursing Implications
Decongestants may cause hypertension, palpitations, and CNS stimulation—avoid in clients with these conditions
Clients on medication therapy for hypertension should check with their physician before taking OTC decongestants
Assess for drug allergies
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Nasal Decongestants:Nursing Implications (cont’d)
Clients should avoid caffeine and caffeine-
containing products
Report a fever, cough, or other symptoms lasting
longer than a week
Monitor for intended therapeutic effects
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Antitussives
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Cough Physiology
Respiratory secretions and foreign objects are naturally removed by the: Cough reflex
Induces coughing and expectoration Initiated by irritation of sensory receptors in the
respiratory tract
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Two Basic Types of Cough
Productive cough
Congested, removes excessive secretions
Nonproductive cough
Dry cough
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Coughing
Most of the time, coughing is beneficial
Removes excessive secretions
Removes potentially harmful foreign substances
In some situations, coughing can be harmful, such as
after hernia repair surgery
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Coughing
Most of the time, coughing is beneficial
Removes excessive secretions
Removes potentially harmful foreign substances
In some situations, coughing can be harmful, such as
after hernia repair surgery
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Antitussives: Definition
Drugs used to stop or reduce coughing
Opioid and nonopioid
(narcotic and nonnarcotic)
Used only for nonproductive coughs!
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Antitussives: Mechanism of Action
Opioids Suppress the cough reflex by direct action on the
cough centre in the medulla
Examples: codeine hydrocodone
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Antitussives: Mechanism of Action (cont’d)
Nonopioids Suppress the cough reflex by numbing the
stretch receptors in the respiratory tract and preventing the cough reflex from being stimulated
Examples: Dextromethorphan, Nyquil, Robitussin
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Antitussives: Indications
Used to stop the cough reflex when the cough is nonproductive and/or harmful
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Antitussives: Side Effects
Dextromethorphan Dizziness, drowsiness, nausea
Opioids Sedation, nausea, vomiting, lightheadedness,
constipation
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Antitussive Agents:Nursing Implications
Perform respiratory and cough assessment, and assess for allergies
Instruct clients to avoid driving or operating heavy equipment due to possible sedation, drowsiness, or dizziness
If taking chewable tablets or lozenges, do not drink liquids for 30 to 35 minutes afterward
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Antitussive Agents:Nursing Implications (cont’d)
Report any of the following symptoms to the caregiver Cough that lasts more than a week A persistent headache Fever Rash
Antitussive agents are for nonproductive coughs Monitor for intended therapeutic effects
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Expectorants
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Expectorants: Definition
Drugs that aid in the expectoration
(removal) of mucus
Reduce the viscosity of secretions
Disintegrate and thin secretions
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Expectorants: Mechanisms of Action
Direct stimulation Reflex stimulation
Final result: thinner mucus that is easier to remove
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Expectorants: Mechanism of Action (cont’d)
Reflex stimulation Agent causes irritation of the GI tract Loosening and thinning of respiratory tract secretions occur
in response to this irritation Example: guaifenesin
Direct stimulation The secretory glands are stimulated directly to increase their
production of respiratory tract fluids Examples: iodine-containing products such as iodinated
glycerol and potassium iodide
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Expectorants: Drug Effects
By loosening and thinning sputum and
bronchial secretions, the tendency to cough is
indirectly diminished
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Expectorants: Indications
Used for the relief of nonproductive coughs associated with:Common coldBronchitisLaryngitisPharyngitisCoughs caused by chronic paranasal sinusitis
PertussisInfluenzaMeasles
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Expectorants:Nursing Implications
Expectorants should be used with caution in the elderly or those with asthma or respiratory insufficiency
Clients taking expectorants should receive more fluids, if permitted, to help loosen and liquefy secretions
Report a fever, cough, or other symptoms lasting longer than a week
Monitor for intended therapeutic effects
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CHAPTER 36
Bronchodilators and Other Respiratory Agents
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Table 36-2 Stepwise approach to the management of asthma
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Table 36-3 Mechanisms of anti-asthmatic drug action
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Diseases of the Lower Respiratory Tract
Bronchial asthma Emphysema Chronic bronchitis COPD Cystic fibrosis Acute respiratory distress syndrome
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Agents Used to Treat Asthma
Long-term control Antileukotrienes Cromoglycate Inhaled steroids Long-acting beta2-agonists
Quick relief Intravenous systemic corticosteroids Short-acting inhaled beta2-agonists
ipratropium nedocromil theophylline
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Bronchodilators and Respiratory Agents
Bronchodilators Xanthine derivatives Beta-adrenergic agonists
Anticholinergics Antileukotrienes Corticosteroids Mast cell stabilizers
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Bronchodilators: Xanthine Derivatives
Plant alkaloids: caffeine, theobromine, and theophylline
Only theophylline is used as a bronchodilator Examples:
aminophyllineTheophyllineSlo-Bid® Uniphyl®
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Xanthine Derivatives: Drug Effects
Cause bronchodilation by relaxing smooth muscles of the airways
Result: relief of bronchospasm and greater airflow into and out of the lungs
Also cause CNS stimulation Slow onset action and are mostly used for
prevention Aminophylline(Status asthmaticus)
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Xanthine Derivatives: Drug Effects (cont’d)
Also cause cardiovascular stimulation: increased force of contraction and increased HR, resulting in increased cardiac output and increased blood flow to the kidneys (diuretic effect)
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Xanthine Derivatives: Indications
Dilation of airways in asthmas, chronic
bronchitis, and emphysema
Mild to moderate cases of acute asthma
Adjunct agent in the management of COPD
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Xanthine Derivatives: Side Effects
Nausea, vomiting, anorexia
Gastroesophageal reflux during sleep
Sinus tachycardia, extrasystole, palpitations,
ventricular dysrhythmias
Transient increased urination
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Nursing Implications: Xanthine Derivatives
Contraindications: history of PUD or
GI disorders
Cautious use: cardiac disease
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Bronchodilators: Beta-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
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Bronchodilators: Beta-Agonists (cont’d)
Three types Nonselective adrenergics
Stimulate alpha-, beta1- (cardiac), and beta2- (respiratory) receptors Example: epinephrine
Nonselective beta-adrenergics Stimulate both beta1- and beta2-receptors Example: isoproterenol
Selective beta2 drugs
Stimulate only beta2-receptors Example: salbutamol
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Beta-Agonists: Indications
Relief of bronchospasm related to asthma,
bronchitis, and other pulmonary diseases
Useful in treatment of acute attacks as well
as prevention
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Beta-Agonists: Side Effects
Beta2 (salbutamol)
Hypotension OR hypertension Vascular headaches Tremor Contraindicated: clients with allergies,
tachyarythmias, severe cardiac disease
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Nursing Implications
Encourage clients to take measures that promote a generally good state of health in order to prevent, relieve, or decrease symptoms of COPD Avoid exposure to conditions that precipitate
bronchospasms (allergens, smoking, stress, air pollutants)
Adequate fluid intake Compliance with medical treatment Avoid excessive fatigue, heat, extremes in temperature,
caffeine
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Nursing Implications (cont’d)
Perform a thorough assessment before beginning therapy, including: Skin colour Baseline vital signs Respirations (should be <12 or >24 breaths/min) Respiratory assessment, including SaO2
Sputum production Allergies History of respiratory problems Other medications
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Nursing Implications (cont’d)
Teach clients to take bronchodilators exactly as prescribed
Ensure that clients know how to use inhalers and MDIs, and have the clients demonstrate use of devices
Monitor for side effects
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Nursing Implications (cont’d)
Monitor for therapeutic effects Decreased dyspnea Decreased wheezing, restlessness, and anxiety Improved respiratory patterns with return to
normal rate and quality Improved activity tolerance
Decreased symptoms and increased ease of breathing
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Anticholinergics: Mechanism of Action
Acetylcholine (ACh) causes bronchial constriction and narrowing of the airways
Anticholinergics bind to the ACh receptors, preventing ACh from binding
Result: bronchoconstriction is prevented, airways dilate
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Anticholinergics
Atrovent (ipratropium bromide) is the only anticholinergic used for respiratory disease
Slow and prolonged action Used to prevent bronchoconstriction NOT used for acute asthma exacerbations! Combivent (salbutamol/ipratroprium)
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Anticholinergics (cont’d)
Side effects: Dry mouth or throat Gastrointestinal distress Headache Coughing Anxiety
No known drug interactions
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Antileukotrienes
Also called leukotriene receptor antagonists
(LRTAs)
Newer class of asthma medications
Three subcategories of agents
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Antileukotrienes (cont’d)
Currently available agents:
Montelukast (sold as Singulair®)
Zafirlukast (sold as Accolate®)
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Antileukotrienes: Mechanism of Action
Leukotrienes are substances released when a trigger, such as cat hair or dust, starts a series of chemical reactions in the body
Leukotrienes cause inflammation, bronchoconstriction, and mucus production
Result: coughing, wheezing, shortnessof breath
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Antileukotrienes: Mechanism of Action (cont’d)
Antileukotriene agents prevent leukotrienes from attaching to receptors on cells in the lungs and in circulation
Inflammation in the lungs is blocked, and asthma symptoms are relieved
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Antileukotrienes: Drug Effects
By blocking leukotrienes: Prevent smooth muscle contraction of the
bronchial airways Decrease mucus secretion Prevent vascular permeability Decrease neutrophil and leukocyte infiltration
to the lungs, preventing inflammation
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Antileukotrienes: Indications
Prophylaxis and chronic treatment of asthma in adults and children older than age 12
NOT meant for management of acute asthmatic attacks
Montelukast is approved for use in children ages 6 and older
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Antileukotrienes: Side Effects
zafirlukast Headache Nausea Diarrhea Liver dysfunction
montelukast has fewer side effects
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Antileukotrienes: Nursing Implications
Ensure that the drug is being used for chronic management of asthma, not acute asthma
Teach the client the purpose of the therapy Improvement should be seen in about
1 week
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Corticosteroids
Anti-inflammatory Used for chronic asthma Do not relieve symptoms of acute
asthmatic attacks Oral or inhaled forms Inhaled forms reduce systemic effects May take several weeks before full
effects are seen
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Corticosteroids: Mechanism of Action
Stabilize membranes of cells that release harmful bronchoconstricting substances
These cells are leukocytes, or white blood cells
Also increase responsiveness of bronchial smooth muscle to beta-adrenergic stimulation
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Inhaled Corticosteroids
Budesonide (Pulmicort®) Fluticasone (Flovent®)
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Inhaled Corticosteroids: Indications
Treatment of bronchospastic disorders that are not controlled by conventional bronchodilators
NOT considered first-line agents for management of acute asthmatic attacks or status asthmaticus
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Inhaled Corticosteroids: Side Effects
Pharyngeal irritation Coughing Dry mouth Oral fungal infections Systemic effects are rare because of the low
doses used for inhalation therapy
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Inhaled Corticosteroids: Nursing Implications
Contraindicated in client with psychosis, fungal infections, AIDS, TB
Cautious use in clients with diabetes, glaucoma, osteoporosis, PUD, renal disease, HF, edema
Teach clients to gargle and rinse the mouth with water afterward to prevent the development of oral fungal infections
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Inhaled Corticosteroids: Nursing Implications (cont’d)
Abruptly discontinuing these medications can lead to serious problems
If discontinuing, should be weaned for 1 to 2 weeks, only if recommended by physician
Report any weight gain of more than 2.5 kg a week or the occurrence of chest pain
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PO corticosteroids
Prednisolone (sold as Pediapred®) Prednisone (sold as Deltasone®)
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Combination Medications
Some pharmaceutical manufacturers have combined two controller medications into one inhaler. These inhalers are referred to as "Combination Medications".
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Combination medications
Combination ® Corticosteroids Budesonide (Pumicort®) Formoterol (Oxeze®) Long-Acting bronchodilator Fluticasone (Flovent®) Salmeterol (Severent®)
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Mast Cell Stabilizers
Cromoglycate (sold as Intal®) Nedocromil (sold as Tilade®) Ketotifen fumarate (sold as Zaditen®)
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Mast Cell Stabilizers: Indications
Adjuncts to the overall management of asthma Used solely for prophylaxis, NOT for
acute asthma attacks Used to prevent exercise-induced bronchospasm Used to prevent bronchospasm associated with
exposure to known precipitating factors, such as cold, dry air or allergens
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Mast Cell Stabilizers: Side Effects
Coughing
Sore throat
Rhinitis
Bronchospasm
Taste changes
Dizziness
Headache
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Mast Cell Stabilizers: Nursing Implications
For prophylactic use only Contraindicated for acute exacerbations Not recommended for children younger than age 5 Therapeutic effects may not be seen for up to 4
weeks Teach clients to gargle and rinse the mouth with
water afterward to minimize irritation to the throat and oral mucosa
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Inhalers:Client Education
For any inhaler prescribed, ensure that the client is able to self-administer the medication Provide demonstration and return demonstration Ensure the client knows the correct time
intervals for inhalers Provide a spacer if the client has difficulty
coordinating breathing with inhaler activation
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Client Education
Metered Dose Inhaler MDI
Spacers
Diskus
Turbuhaler
Nebulized
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Inhalers fall into two categories
Aerosol Inhalers: Pressurized metered dose inhaler is a canister filled with asthma medication suspended in a
propellant. When the canister is pushed down, a measured dose of the medication is pushed out as you breathe it in. Pressurized metered dose inhalers are commonly called
"puffers". Dry-powder inhalers: Dry powdered inhalers contain a dry
powder medication that is drawn into your lungs when you breathe in.
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Spacers should always be used with MDIs that deliver inhaled corticosteroids. Spacers can make it easier for medication to reach the lungs, and also mean less medication gets deposited in the mouth and throat, where it can lead to irritation and mild infections. The Asthma
Society of Canada recommends that anyone, of any age, using a puffer, consider using a spacer.
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END OF LECTURE