Respiratory and Steroids

What types of drugs can decrease cough and respirations?

• Morphine

• Alcohol

• Sedatives (Barbiturates, Benzodiazepines)

• CNS Depressants

• Beta Blockers

• Cholinergics (PNS Mimetics)

• Promethazine (Phenergan

Which drug is an opioid that decreases cough and respirations?

Morphine

Which commonly used substance depresses the CNS and decreases respirations?

Alcohol

Which sedative classes can cause respiratory depression?

Barbiturates and Benzodiazepines

What drug class as a whole decreases CNS activity and respiratory drive?

CNS Depressants

Which cardiovascular drug class can reduce respiratory drive?

Beta Blockers

Which class of drugs (also called PNS Mimetics) can decrease respirations?

Cholinergics

Which antihistamine can cause bronchospasm and increased mucus?

Promethazine (Phenergan)

What are the 4 main types of OTC cold remedies?

• Antihistamines

• Decongestants

• Expectorants

• Antitussives

What is the mechanism of action (MoA) of antihistamines?

Block histamine at receptor sites and inhibit bronchial constriction.

What are the main uses of antihistamines?

• Allergic rhinitis

• Pruritis (itching)

What are common side effects of antihistamines?

• Sedation

• Dry mouth

• Constipation

• Blurred vision

• Urinary retention

In which patients should antihistamines be used with caution?

• Bronchial asthma

  • because you are drying everything out

• Increased intraocular pressure

• Benign prostatic hyperplasia (BPH)

• Elderly

What unusual effect can antihistamines cause in children?

Paradoxical excitement

• opposite effect than the normal

What are two examples of antihistamines?

• Promethazine (Phenergan)

• Loratadine (Claritin)

What are 5 common OTC antihistamines?

• Loratadine (Claritin)

• Diphenhydramine (Benadryl)

• Brompheniramine (Dimetapp)

• Chlorpheniramine (Chlor-Trimeton)

• Clemastine (Tavist)

What is the mechanism of action (MoA) of decongestants?

Constrict dilated blood vessels in nasal mucosa by stimulating alpha-adrenergic receptors in vascular smooth muscle → ↓ blood flow, ↓ mucus formation, ↓ drainage.

What are examples of common decongestants?

• Adrenalin/Epinephrine

• Ephedrine

• Vicks Inhaler

• Afrin

• Sudafed

• Neo-Synephrine

What conditions are contraindications for decongestant use?

• Hypertension (HTN)

• Heart disease

• Diabetes mellitus (DM)

• Hyperthyroidism

What are common side effects of decongestants?

• Headache

• Insomnia

  • thats why there is dayquil and nyquil

• Nervousness

• Palpitations

What can happen with overuse of nasal decongestant sprays (e.g., Afrin)?

Rebound nasal congestion

• physical dependence

• started afrin and never stopped

What are 3 common OTC decongestants?

• Oxymetazoline (Afrin)

• Pseudoephedrine (Sudafed – behind the counter)

• Phenylephrine (Sudafed – in the aisles)

Which OTC decongestant should not be used for more than 3 days?

Oxymetazoline (Afrin)

Which OTC decongestants should not be used for more than 7 days?

• Pseudoephedrine (Sudafed – behind the counter)

• Phenylephrine (Sudafed – in the aisles)

What is the difference between pseudoephedrine and phenylephrine Sudafed?

• Pseudoephedrine: Kept behind the counter

• Phenylephrine: Found in the aisles

What is a common expectorant medication?

Guaifenesin (Robitussin)

• mucinex 

What is the mechanism of action (MoA) of expectorants?

• Increase flow of respiratory secretions

• Decrease viscosity of bronchial secretions & phlegm

  • so it doesnt get cought

• Increase ciliary action to help remove mucus with cough

  • so when you do cough, you will cough more stuff up

• Increase hydration in the respiratory tract → forms a soothing coating

What is a common side effect of expectorants?

Nausea (due to increased gastric secretions)

What teaching point should be included when giving an expectorant?

Teach the patient how to cough effectively to clear mucus.

What is the mechanism of action (MoA) of antitussives?

Suppress the cough reflex by depressing the cough center in the medulla.

What are examples of narcotic antitussives?

• Codeine

• Hydrocodone

What are possible side effects of narcotic antitussives?

• Dependence

• Respiratory depression

• Bronchial constriction

• CNS depression

• Constipation

What is an example of a non-narcotic antitussive?

Dextromethorphan (Robitussin DM)

• works on cough center but works without an opioid effects

What are the benefits of non-narcotic antitussives like dextromethorphan?

• Acts on cough center without respiratory depression

• No analgesia

• No dependence

• Short-term use for dry, hacking coughs

When should non-narcotic antitussives not be used?

Do not use with moist, productive coughs.

Antitussives safety

reasonably safe and effective

Is oxygen considered a drug?

Yes, it requires a provider’s order.

How is oxygen typically dosed?

• Liters per minute (LPM)

• Percentage (%)

What are typical oxygen delivery ranges for a nasal cannula and a venti mask?

• Nasal cannula: 1–6 LPM

• Venti mask: 21–100%

Why should oxygen doses over 45% be used cautiously?

They increase the risk of lung damage.

• it can cause damage over time 

What are key safety precautions when using oxygen?

• Oxygen is flammable

• No smoking

• Keep away from flammable liquids (e.g., alcohol)

• Avoid oil and wool blankets

LPM and % relationship

• room air is 21%

everytime you add a liter of O2, you are adding about 3 or 4% of Oz

Look back over patho of asthma

What type of disorder is asthma?

Chronic inflammatory disorder of the airway.

What are the characteristic signs and symptoms of asthma?

• Sense of breathlessness

• Tightening of the chest

• Wheezing

• Dyspnea

• Cough

What is the underlying cause of asthma?

Immune-mediated airway inflammation.

What type of disorder is COPD?

Chronic, progressive, largely irreversible disorder characterized by airflow restrictions and inflammation.

What are the characteristic signs and symptoms of COPD?

• Chronic cough

• Excessive sputum production

What are the primary pathologies associated with COPD?

• Chronic bronchitis

• Emphysema

LOOK BACK AT PATHO OF THOSE

What are the two main pharmacologic classes used for asthma and COPD?

• Anti-inflammatory agents

• Bronchodilators

Which drug class is anti-inflammatory for asthma and COPD?

Glucocorticoids

What is an example of a bronchodilator?

Beta2 agonists

Which drugs are used for long-term management of asthma and COPD?

• Glucocorticoids

• Mast cell stabilizers

• Beta2 agonists

• Methylxanthines

• Leukotriene modifiers

Which drugs are used for short-term relief of asthma and COPD?

• Beta2 agonists

• Anticholinergics

• Corticosteroids

rescue inhaler

What are the main benefits of inhalation drug therapy?

• Therapeutic effects are enhanced

• Systemic effects are minimized

• Relief of acute attacks is rapid

What are the three obvious advantages of inhalation therapy?

• Rapid relief of symptoms

• Targeted delivery to lungs

• Lower systemic side effects

What are the three main types of inhalation devices?

• Metered-dose inhalers (MDIs) / Respimats – soft mist inhaler

• Dry-powder inhalers (DPIs)

• Nebulizers

What are the pros and cons of a Metered-Dose Inhaler (MDI)?

Pros:

• Non-breath activated

  • you dont have to breath in to get it so good for those having hard time to deep breath

• Multidose delivery

• Portable

• Cheap

Cons:

• Requires good coordination to inhale and press canister simultaneously

• Technique dependent

What are the pros and cons of a Soft Mist Inhaler (Respimat)?

Pros:

• Superior lung deposition

• Easier to use than MDI

• Non-breath activated

Cons:

• Still requires some coordination

• More expensive

• Needs assembly and priming

What are the pros and cons of a Dry-Powder Inhaler (DPI)?

Pros:

• No coordination needed

• Rapid and efficient delivery

• Portable and easy to use

Cons:

• Requires a forceful breath for adequate lung deposition

• Dose can be affected by heat and humidity

What are the pros and cons of a Nebulizer?

Pros:

• Inexpensive for inpatient settings

• Good for CF patients

• No patient effort needed

Cons:

• Inconvenient

• Time-consuming

  • you need to wait a minute in between each puff

  • if doing separate med puffs, you need to wait 3-4 minutes between each puff

What is the mechanism of action of glucocorticoids like budesonide?

• Decrease synthesis and release of inflammatory mediators

• Reduce infiltration and activity of inflammatory cells

  • stops inflam immune process

• Decrease edema of the airway mucosa

• Considered the most effective antiasthma drugs

What is the main use of inhaled glucocorticoids?

Prophylaxis of chronic asthma; not for aborting acute attacks.

How should glucocorticoids be dosed?

On a fixed schedule, not as needed (PRN).

• it will not help an acute attack

What are the common routes of administration for budesonide?

• Inhalation (most common)

• Intravenous (IV)

• Oral

How should glucocorticoid therapy be discontinued?

• Must be done slowly

• Allows recovery of adrenocortical function over several months

• Gradually reduce dosage of exogenous sources

• Patients may need supplemental oral or IV glucocorticoids during severe stress

What are common adverse effects of inhaled glucocorticoids?

• Oropharyngeal candidiasis

  • thrush

  • yeast infection in mouth

  • do an oral rinse

• Dysphonia (hoarseness)

• Adrenal suppression

  • body stops making those hormones on own bc your taking them

• Osteoporosis

• Growth suppression

• Skin thinning and easy bruising

Why might patients on inhaled glucocorticoids need supplemental systemic glucocorticoids?

During periods of severe stress, because adrenocortical function may be suppressed.

• cannot just stop cold turkey

glucocorticoids

During this time, patients—including
those switched to inhaled
glucocorticoids—must be given
supplemental oral or IV
glucocorticoids at times of severe
stress

What is the mechanism of action of beta2 agonists like albuterol?

• Activate beta2 receptors in lung smooth muscle → bronchodilation → relieve bronchospasm

• Limited effect on histamine suppression and cilia motility; used as adjunct with anti-inflammatory therapy

What are common adverse effects of inhaled beta2 agonists?

• Tachycardia

• Angina

• Tremor

• Hypokalemia

Why are beta2 agonists often used with anti-inflammatory therapy?

Because they provide bronchodilation but have limited anti-inflammatory effects, so they complement anti-inflammatory drugs for optimal asthma/COPD management.

When are short-acting beta2 agonists (SABAs) used?

• PRN to abort an ongoing asthma attack

• Exercise-induced bronchospasm (EIB): taken before exercise

• Severe acute attacks in hospitalized patients: nebulized SABA

• Outpatient: MDI delivery may be equally effective

When are long-acting beta2 agonists (LABAs) used?

• Long-term control for patients with frequent attacks

• Fixed schedule dosing, not PRN

• Effective for stable COPD

• In asthma, must always be combined with a glucocorticoid

• Use alone in asthma is contraindicated

Why must LABAs never be used alone in asthma?

Because they do not have anti-inflammatory effects, and using them alone increases the risk of severe asthma exacerbations.

How do SABAs and LABAs differ in administration?

• SABAs: PRN for relief of acute symptoms; may be nebulized or MDI

• LABAs: Fixed schedule for long-term control; inhaled, always with glucocorticoid in asthma

What is the mechanism of action of theophylline?

• Produces bronchodilation by relaxing smooth muscle of the bronchi

• Increases diaphragm contractility

• Enhances mucociliary clearance

What is the usual route of administration for theophylline?

• Oral (maintenance therapy for chronic stable asthma)

• May also be administered intravenously

What is the therapeutic plasma level range for theophylline?

10–20 mcg/mL

What adverse effects occur at plasma levels of 20–25 mcg/mL?

• Nausea, vomiting, hematemesis

• Diarrhea

• Insomnia

• Restlessness

What severe toxic effects occur at plasma levels above 30 mcg/mL?

• Severe dysrhythmias (e.g., ventricular fibrillation)

• Convulsions

• Potential death from cardiorespiratory collapse

What is the treatment for theophylline toxicity?

• Stop theophylline

• Administer activated charcoal with a cathartic

  • make them throw up

• Treat dysrhythmias

• IV diazepam may help control seizures

What are common adverse effects of theophylline?

• Insomnia

• Gastric upset (↑ risk of ulcer or reflux)

• Hyperactivity

• Dysuria in elderly males with prostatism

What substances or drugs interact with theophylline?

• Caffeine

• Tobacco and marijuana

• Cimetidine

• Fluoroquinolone antibiotics

What is the drug of choice for acute bronchospasm?

Beta2-adrenergic agonists, such as albuterol and terbutaline.

When are albuterol and terbutaline commonly used?

• To relieve acute bronchospasm

• Pre-exercise to prevent exercise-induced bronchospasm

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What is the mechanism of action of albuterol and terbutaline?

• Bronchodilation via smooth muscle relaxation

• Antagonism of bronchoconstriction mechanisms

What are common adverse effects of quick-relief beta2 agonists?

• Tachycardia

• Skeletal muscle tremor

• Hypokalemia

• Increased lactic acid

• Headache

• Hyperglycemia

What is the mechanism of action of ipratropium?

Blocks muscarinic receptors in the bronchi → reduces bronchoconstriction → improves lung function.

How is ipratropium administered and used?

• Administered by inhalation to relieve bronchospasm

• Therapeutic effects begin within 30 seconds, reach 50% maximum in 3 minutes, and persist about 6 hours

• Treatment of choice for bronchospasm caused by beta-blocker medications

  • you get it from beta  even faster

  • you dont reach for this drug first for excerise induced. you reach for betas

What are common adverse effects of ipratropium?

• Dry mouth and pharynx irritation

• Glaucoma

• Cardiovascular events

• Decreased mucus gland secretion

What are some common glucocorticoid/LABA combination inhalers?

• Budesonide/formoterol (Symbicort)

• Fluticasone/vilanterol (Breo Ellipta)

• Fluticasone/salmeterol (Advair)

• Mometasone/formoterol (Dulera)

What is the primary indication for glucocorticoid/LABA combination inhalers?

• Long-term maintenance in adults

• Restricted use in children

• Not recommended for initial therapy

you still get the same side effects but also add in side effects form beta 2

What are the main goals in treating an acute exacerbation of asthma or COPD?

• Relieve airway obstruction

• Correct hypoxemia

• Normalize lung function as quickly as possible

What is the initial therapy for an acute exacerbation?

1. Oxygen – to relieve hypoxemia

2. Systemic glucocorticoid – to reduce airway inflammation

3. Nebulized, high-dose SABA – to relieve airflow obstruction

4. Nebulized ipratropium – to further reduce airflow obstruction

Why are both SABA and ipratropium used in acute exacerbations?

• SABA: Rapid bronchodilation

• Ipratropium: Adds additional bronchodilation via anticholinergic mechanism, enhancing airflow relief

What causes exercise-induced asthma (EIA)?

Bronchospasm secondary to loss of heat and/or water from the lungs during exercise.

When does exercise-induced asthma typically start, peak, and resolve?

• Starts during or immediately after exercise

• Peaks in 5–10 minutes

• Resolves in 20–30 minutes

Which drugs are used prophylactically for exercise-induced asthma?

• Short-acting beta2 agonists (SABAs) – generally preferred

• Cromolyn

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When should SABAs and cromolyn be inhaled for exercise-induced asthma?

• SABAs: Immediately before exercise

• Cromolyn: 15 minutes before exercise