Drug Therapy for Nasal Congestion & Cough

Upper Respiratory Tract

• Rhinitis

  • Common cold versus allergic

  • Nasal passage inflammation

  • Rhinovirus/Corona virus

• Rhinosinusitis AKA “sinus infection”

  • Sinus pressure, fever, purulent postnasal and nasal drainage

  • Most are viral initially

Treatment: Nursing considerations/teaching

• Rest, hydration, humidifier, analgesics, cough drops, saline nasal sprays/drops, good handwashing !

• Good assessment, good history

• Age special considerations for the very young and old

• Comorbidities

Nasal Decongestants

• Indication:decrease secretions

• Action:

  • sympathomimetics

    • Increased heart rate, blood pressure

    • Vasoconstriction

• Contraindications

  • CAD, HTN, Renal Disease

  • Caution:DM glaucoma hyperthyroidism

Nasal Decongestants - Topical

• Oxymetazoline (Afrin)

  • Route- nasal

  • Onset 5-10 minutes

  • Duration 6-10 hours

Nasal Decongestants - Oral

• Pseudoephedrine (Sudafed)

  • Route – oral

  • Onset 30 minutes

  • Duration: 4-8 hours

  • Must be older than 4 years

  • Drug to drug: cocaine, MOA inhibitors, heart medication

Antitussives

• Indication:

  • Stop the nonproductive cough

• Action:

  • Depress cough reflex

• Contraindications

  • Allergy, CHI, pregnancy, lactation

• Pharmacokinetics

  • Metabolized in the liver

• Route

  • Oral, onset 25-30 minutes, peak 2 hours, duration 3-6 hours

• Adverse Reactions:

  • Dries mucus membranes

  • Increases the viscosity of secretions

  • Respiratory depression

• Drug-Drug

  • MAO inhibitors

Antitussives meds

• Prototype:

  • Dextromethorphan

    • Seen in Robitussin

    • Will see in medications as DM

    • Acts in medulla oblongata

  • Benzonatate (Tessalon)

    • Action: local anesthetic on respiratory passages DOES NOT ACT CENTRALLY

    • Adverse reaction: chest pain, dizziness, confusion, hallucinations

Antitussives nursing considerations

• Patient teaching

• Good assessment

  • Combination medication

  • Home medications

  • Age- elderly risk falls, children

  • Assess social habits

    • Alcohol intensifies this medication

  • Can cause constipation

• Medication effectiveness:

  • Improved cough

Expectorants

• Indication:

  • Symptomatic relief of dry nonproductive cough in the PRESENCE of mucus

• Action:

  • Liquifies lower respiratory tract secretions, reduces viscosity

• Contraindication:

  • Allergy, caution pregnancy/lactation

• Pharmacokinetics: metabolized and excreted in urine

  • Onset 30 minutes, duration is based on dosing

• Route: oral

• Adverse reactions:

  • headache, rash

• Contraindication: allergy

• Drug to Drug

Expectorants Medications

• Prototype:

  • Guaifenesin (Mucinex)

    • Multiple choices

    • Added to multiple OTC cold meds

    • Limited data in children (<4)

    • Children < 12 should NOT have extended release form.

Expectorants Nursing Considerations

• Patient teaching

• Good assessment

  • Combination medication

  • Home medications

  • Age- elderly risk falls, children

  • Assess social habits

    • Alcohol intensifies this medication

  • Can cause constipation

• Medication effectiveness:

  • Improved cough

Mucolytics: Acetylcysteine (Mucomyst)

• Indication:

  • Patients with viscous mucus

    • Atelectasis, postop, trach patients

• Action:

  • Liquifies mucus by attacking the protein bond

• Contraindications:

  • Acute bronchospasm, PUD, esophageal varices

• Pharmacokinetics:

  • Instillation (trach), inhalation onset 1 hour, duration 2-3 hours, oral onset 30-60 min, peak 1-2 hours

• Route:

  • Inhalation (nebulizer), oral

• Adverse reactions:

  • GI, stomatitis , rhinorrhea, bronchospasm

Histamine

• 1st mediator released in

  • Immune and inflammatory responses

  • Stored in most body tissues

  • Discharged from Mast cells & Basophils

• H1 & H2 receptors

  • H1: smooth muscle in blood vessels/GI and respiratory tracts

• Actions:

  • Smooth muscle contraction

  • Stimulates vagus nerve endings

  • Increased permeability of veins/capillaries

  • Increased mucus secretions

  • Stimulation of sensory nerve endings

TYPE 1 “One antibody named IgE, causes the body to release histamine”

• Food Allergic reactions

  • Shellfish, nuts, eggs, mild

  • Patients with type I allergic reactions carry epi pens

  • Children

• Drug Allergies: PCN

• Covered in shock and chapter 16

• Characterized as mild, severe or life-threatening

Type 2: ” two antibodies attacking me, named IgM & IgG”

• Blood transfusion reaction

• Produces autoantibodies

• ABO incompatibility

• Goodpasture syndrome

• Hyperthyroidism- Graves Disease

• Autoimmune hemolytic anemia

Type III: “ Three complex get the hint, as it involves the compliment”

• Formation of antigen-antibody complexes

  • Acute inflammatory response

• Serum sickness

  • Characterized by:

    • Fever rash polyarthralgia’s

  • Persons who get antivenom

Type IV: “4 T cells like to raid, but the response if more delayed”

• Cell-mediated response

  • T lymphocytes react with antigen & cause inflammation.

• Lag time

• TB skin test

• Contact dermatitis

  • Poison ivy

• Graft rejection

Allergic Rhinitis – Type I

• Seasonal:

  • Response to airborne

  • Hay fever

• Perennial:

  • Nonseasonal

    • Dust, mold, animals, tobacco smoke

• Exposure causes the release of Histamine!

Antihistamines 1st Generation

• Action:

  • Block H1 receptors

• Pharmacokinetics:

  • Onset:15-60 minutes

  • Duration: 4-12 hours

• Indication:

  • Hypersensitivity reactions, motion sickness, insomnia.

• Adverse reactions:

  • Excessive drowsiness, confusion, difficulty urinating, paradoxical excitement

• Cautions:

  • pregnancy, BPH, narrow angle glaucoma.

• Drug to Drug:

  • Alcohol, MAOI

Antihistamines 1st Generation: Diphenhydramine (Benadryl)

• Route:

  • IM, IV, po

• Dosage:

  • Weight based for children

  • Older adults- go low & slow

Antihistamines 1st Generation: Promethazine

• Used for nausea/vomiting

• Seen in antitussives

• BBW: cannot be given IVP

Antihistamines: 2nd Generation

• Action:

  • Competes with Histamine

• Pharmacokinetics:

  • Onset: peak 1 hour

• Indications:

  • Temporary relief of allergic rhinitis

• Adverse reactions:

  • Drowsiness, headache, NV

• Contraindications:

  • Known allergy

Antihistamines: 2nd Generation Cetirizine (Zyrtec)

• Route: oral

• Dosage: daily, weight based in children

Antihistamines: 2nd Generation Azelestine

• Route: Nasal

• Dosage: 1-2 actuations/nostril

• Children: 5 years and older

• Considered 1st line of treatment

Antihistamines: 3rd Generation

• Action:

  • Bind peripherally to H1 receptors

  • Does not cross blood brain barrier

• Pharmacokinetics:

  • Peak: 2.5 hr, duration: 12-24 hr

• Indication:

  • Seasonal allergies/urticaria

• Adverse Reactions:

  • Minor, headache, nausea

• Contraindications:

  • Sensitivity

Antihistamines: 3rd Generation Fexofenadine (Allegra)

• Route: oral

• Dosage: daily, weight based in kids

• Special consideration:

• Should be taken with H2O

  • Take on empty stomach

  • Food/Herbs

    • Fruit juice

    • St john’s Wort

    • High fat meals