Respiratory AgentsRespiratory Agents

PharmacologyPharmacology

Clinical Management of Diseases Clinical Management of Diseases of the Lungsof the Lungs

Pathology Of AsthmaPathology Of Asthma

Increased responsiveness of trachea & Increased responsiveness of trachea & bronchi to various stimuli which trigger….bronchi to various stimuli which trigger….

Constriction of airwaysConstriction of airways Increased mucous secretionsIncreased mucous secretions Increased inflammation & edema causing..Increased inflammation & edema causing..

– Recurrent/episodic bouts of SOB, wheeze, tight Recurrent/episodic bouts of SOB, wheeze, tight chestchest

Reversible!Reversible!

Symptoms Goals of CareSymptoms Goals of Care

WheezingWheezing CoughCough DyspneaDyspnea Acute and chronicAcute and chronic

Function in daily lifeFunction in daily life Freedom from Freedom from

wheezingwheezing Control of coughingControl of coughing Tolerate medicationsTolerate medications 5-10% asthmatics are 5-10% asthmatics are

hypersensitive to hypersensitive to aspirinaspirin

Chemical Components of CigarettesChemical Components of CigarettesChemical Standard UseChemical Standard Use

Carbon Monoxide Carbon Monoxide Car exhaustCar exhaust

NicotineNicotine PesticidesPesticides

AmmoniaAmmonia Floor cleanersFloor cleaners

ArsenicArsenic White ant poisonWhite ant poison

ButaneButane Lighter fuelLighter fuel

Hydrogen cyanideHydrogen cyanide Poison used in gas Poison used in gas chamberschambers

TolueneToluene Industrial solventIndustrial solvent

DDTDDT InsecticidesInsecticides

Time of Last Cigarette & EffectTime of Last Cigarette & Effect

Within 20 minutesWithin 20 minutes BP/P returns to normalBP/P returns to normal

Temp hands/feet increase back to Temp hands/feet increase back to normal Stops polluting the airnormal Stops polluting the air

After 8 hoursAfter 8 hours Blood carbon monoxide dropsBlood carbon monoxide drops

Blood O2 returns to normalBlood O2 returns to normal

After 24 hoursAfter 24 hours Chance of heart attack Chance of heart attack decreasesdecreases

Within 48 hoursWithin 48 hours Nerve endings re-adjust sense of Nerve endings re-adjust sense of smell/taste enhancedsmell/taste enhanced

After 72 hoursAfter 72 hours Bronchial tubes relax lung Bronchial tubes relax lung capacity increasescapacity increases

2 weeks to 3 months2 weeks to 3 months Circulation/walking improveCirculation/walking improve

Lung function up 30%Lung function up 30%

1 month to 9 months1 month to 9 months Cilia re-grow, handle mucus & Cilia re-grow, handle mucus & clean lungs reduce infectionclean lungs reduce infection

Energy level increasesEnergy level increases

1 year1 year Heart dz death rate halfway Heart dz death rate halfway back to that of a non-smokerback to that of a non-smoker

5 years5 years Heart dz death rate drops to rate for Heart dz death rate drops to rate for non-smokers; lung CA death rate non-smokers; lung CA death rate decreases halfway to non-smokerdecreases halfway to non-smoker

10 year projection10 year projection Lung CA rate almost same for non Lung CA rate almost same for non smoker, precancerous cell smoker, precancerous cell replaced, incidence mouth, larynx, replaced, incidence mouth, larynx, esophag, bladder, kidney, pancreas esophag, bladder, kidney, pancreas CA dec.CA dec.

Reasons People SmokeReasons People SmokeTop FIVETop FIVE

It’s a habitIt’s a habit I’m addictedI’m addicted It relaxes meIt relaxes me I enjoy itI enjoy it Something to do with my handsSomething to do with my hands

Reasons Why Smokers Do Not Try Reasons Why Smokers Do Not Try to Quitto Quit

Fear of withdrawalFear of withdrawal CravingsCravings Loss of way to handle stressLoss of way to handle stress Cost of medicinesCost of medicines Fear cannot quitFear cannot quit

Five MYTHS about quitting smokingFive MYTHS about quitting smoking

Smoking is just a bad habit.Smoking is just a bad habit.– Fact: Tobacco use is an addiction.Fact: Tobacco use is an addiction.

Quitting is just a matter of will power.Quitting is just a matter of will power.– Fact: Quitting is difficult.Fact: Quitting is difficult.

If you can’t quit the 1If you can’t quit the 1stst time, you will never. time, you will never.– Fact: Quitting is hard & usually takes 2-3 tries.Fact: Quitting is hard & usually takes 2-3 tries.

The best way to quit is ‘cold turkey’.The best way to quit is ‘cold turkey’.– Fact: Most effective way is a combination of Fact: Most effective way is a combination of

counseling & nicotine replacement therapycounseling & nicotine replacement therapy

Quitting is expensive.Quitting is expensive.– Fact: Treatments cost $3-14 per day. A pack a Fact: Treatments cost $3-14 per day. A pack a

day smoker spends almost $1200 per year. day smoker spends almost $1200 per year. Many health insurances cover medication & Many health insurances cover medication & counseling.counseling.

Clinical Management of Respiratory Clinical Management of Respiratory DiseasesDiseases

Acute CareAcute Care

Chronic CareChronic Care

Stepped CareStepped Care Peak Flow MeterPeak Flow Meter SpacerSpacer OxygenOxygen

RelieverReliever– AcuteAcute

ControllerController– Maintenance Maintenance – ChronicChronic– ProphylacticProphylactic

Stepwise Pharmacologic Stepwise Pharmacologic TherapyTherapy

Step 1 Mild intermittentStep 1 Mild intermittent– Symptoms < 2x/wkSymptoms < 2x/wk

Step 2 Mild persistentStep 2 Mild persistent– Symptoms >2x/wkSymptoms >2x/wk

Step 3 Moderate Step 3 Moderate persistentpersistent– Daily symptoms affect Daily symptoms affect

activityactivity– Exacerbations >2x/wkExacerbations >2x/wk

Step 4 Severe Step 4 Severe persistentpersistent– Continual symptomsContinual symptoms

OVERVIEW Therapeutic AgentsOVERVIEW Therapeutic Agents Mast Cell StabilizersMast Cell Stabilizers

– CromolynCromolyn Xanthine DerivativesXanthine Derivatives

– AminophyllineAminophylline Bronchodilators ( short & long acting)Bronchodilators ( short & long acting)

– Sympathomimetics (albuterol)Sympathomimetics (albuterol) Anti-MuscarinicAnti-Muscarinic

– Ipratropium (Atrovent)Ipratropium (Atrovent) CorticosteroidsCorticosteroids Leukotriene InhibitorsLeukotriene Inhibitors (Singulair, Accolate) (Singulair, Accolate)

Xanthine DerivativesXanthine Derivatives

MethylxanthinesMethylxanthines– TheophyllineTheophylline– AminophyllineAminophylline

MOAMOA ToxicityToxicity

BronchodilatorsBronchodilators

SympathomimeticsSympathomimetics– EphedrineEphedrine– EpinephrineEpinephrine– Beta-2 agentsBeta-2 agents

Albuterol Albuterol SalmeterolSalmeterol MetaproterenolMetaproterenol

– MOAMOA– ToxicityToxicity– DependenceDependence

BronchodilatorsBronchodilators

Anti-CholinergicsAnti-Cholinergics– Anti-MuscarinicsAnti-Muscarinics

AtropineAtropine Ipratropium Bromide (Atrovent)Ipratropium Bromide (Atrovent)

MOAMOA ToxicityToxicity

Corticosteroids Corticosteroids Mast Cell Stabilizers Mast Cell Stabilizers CorticosteroidsCorticosteroids– BeclomethasoneBeclomethasone– Budesonide (Pulmicort)Budesonide (Pulmicort)– Fluticasone(Flovent)Fluticasone(Flovent)– Triamcinolone Triamcinolone

(Azmacort)(Azmacort)– Mometasone (Nasonex)Mometasone (Nasonex)

MOAMOA ToxicityToxicity

– Oral candidiasisOral candidiasis

Mast Cell StabilizersMast Cell Stabilizers– Cromolyn (Intal)Cromolyn (Intal)

MOAMOA ToxicityToxicity

Leukotriene InhibitorsLeukotriene Inhibitors

Leukotriene Pathway Leukotriene Pathway InhibitorsInhibitors– Monelukast (Singulair)Monelukast (Singulair)– Zafirlukast (Accolate)Zafirlukast (Accolate)

MOAMOA ToxicityToxicity

Summary SlideSummary Slide

Clinical Management of Respiratory DiseasesClinical Management of Respiratory Diseases Stepwise Pharmacologic TherapyStepwise Pharmacologic Therapy Pharmacologic AgentsPharmacologic Agents

– Xanthine DerivativesXanthine Derivatives– BronchodilatorsBronchodilators– Leukotriene InhibitorsLeukotriene Inhibitors– Corticosteroids Corticosteroids

Mast Cell Stabilizers Mast Cell Stabilizers

Smoking CessationSmoking Cessation

Behavior Modification & Reward AbstinenceBehavior Modification & Reward Abstinence– Set a date, inform friends, family, coworkers to Set a date, inform friends, family, coworkers to

understand and support.understand and support. Avoid triggersAvoid triggers

– Remove cigarettes from environment & avoid Remove cigarettes from environment & avoid where smoking is prevalent.where smoking is prevalent.

Anticipate challengesAnticipate challenges– Critical first few weeks of withdrawal effects.Critical first few weeks of withdrawal effects.– Nicotine replacement and concurrent therapy.Nicotine replacement and concurrent therapy.

Common Agents Common Agents

Nicotine ReplacementNicotine Replacement– Gum/PatchGum/Patch– Inhaler/Nasal SprayInhaler/Nasal Spray– Lozenge/WaterLozenge/Water

AntidepressantAntidepressant– Bupropion (Zyban, Bupropion (Zyban,

Wellbutrin)Wellbutrin)

Support Support

1-800 NO BUTTS1-800 NO BUTTS

CASE STUDY Antibiotics and CASE STUDY Antibiotics and RespiratoryRespiratory

TL is a 29-year-old female, 59 kg, who TL is a 29-year-old female, 59 kg, who presents at clinic with a 2-week history of presents at clinic with a 2-week history of abdominal pain, nocturia and frequency of abdominal pain, nocturia and frequency of urination. PE is unremarkable except some urination. PE is unremarkable except some lower abdominal tenderness. A clean catch lower abdominal tenderness. A clean catch midstream urine sample is collected. The midstream urine sample is collected. The results are 10-25 WBC/HPF with a few results are 10-25 WBC/HPF with a few gram-positive cocci in clusters and gram gram-positive cocci in clusters and gram negative rods. She is empirically started on negative rods. She is empirically started on Macrobid 100mg bid x 7 days. TL returns to Macrobid 100mg bid x 7 days. TL returns to clinic 3 days later with a productive cough, clinic 3 days later with a productive cough, wheezing, and heaviness on her chest and wheezing, and heaviness on her chest and shaking chills. She is severely nauseous. shaking chills. She is severely nauseous. Her breathing is labored with rales and Her breathing is labored with rales and wheezing. Pregnancy results are positivewheezing. Pregnancy results are positive..

Points to PonderPoints to Ponder

Discuss her symptoms and relate them Discuss her symptoms and relate them to a possible health problem.to a possible health problem.

Discuss the antibiotic empiric Discuss the antibiotic empiric treatment. Should it be changed?treatment. Should it be changed?

Consider the relationship between Consider the relationship between pregnancy and UTI.pregnancy and UTI.

What respiratory therapy would you What respiratory therapy would you consider?consider?