Updated Drug Therapies for Nasal Congestion, Cough, and to Decrease Histamine Effects and Allergic Responses

For which of the following reasons should a client attach a spacer to a metered dose inhaler?

A. ​To increase the amount of drug delivered to the lungs

B. To increase the amount of drug delivered to the oropharynx

C. To increase the amount of drug delivered on exhalation

D. To increase the speed of drug delivery into the mouth

A. ​To increase the amount of drug delivered to the lungs

A nurse is caring for a client who is having difficulty mobilizing thick respiratory secretions. Which of the following drugs should the nurse expect to administer to the client?

A. Ipratropium

B. Beclomethasone

C. Acetylcysteine

D. Azelastine

C. Acetylcysteine

A nurse is teaching a client who has a prescription for zileuton. Which of the following instructions should the nurse include?

A. Check apical pulse before taking the drug.

B. Take the drug only as needed before exercising.

C. Rinse mouth after using the drug.

D. Have laboratory tests performed at regular intervals.

D. Have laboratory tests performed at regular intervals.

A nurse is teaching a client about the use of an expectorant to treat a cough. The nurse should include that an expectorant has which of the following therapeutic effects?

A. Suppresses the cough stimulus

B. Reduces surface tension

C. Reduces inflammation

D. Dries mucous membranes

B. Reduces surface tension

A nurse is teaching a client about using intranasal glucocorticoids. Which of the following instructions should the nurse give?

A. Start at a low dose and gradually increase it.

B. Take the drug as needed for nasal congestion.

C. Allow at least 2 weeks for the full therapeutic effect.

D. Use the drug prior to exercise.

C. Allow at least 2 weeks for the full therapeutic effect.

A nurse is teaching a client who is beginning fluticasone propionate/salmeterol therapy. Which of the following instructions should the nurse include?

A. Take the drug as needed for acute asthma.

B. Follow a low-sodium diet.

C. Use an alternate-day dosing schedule.

D. Increase weight-bearing activity.

D. Increase weight-bearing activity.

A nurse should identify that dextromethorphan can have which of the following effects when combined with morphine?

A. Reduced antitussive effect of dextromethorphan

B. Potentiation of depression of CNS actions

C. Increased renal reabsorption of the dextromethorphan

D. Delayed analgesic effect of the opioid

B. Potentiation of depression of CNS actions

For which of the following reasons should a nurse instruct a client to avoid taking guaifenesin with combination over-the-counter cold products?

A. Over-the-counter cold products can also contain guaifenesin.

B. Blood glucose levels are increased.

C. Rebound congestion is likely.

D. Drug tolerance is likely.

A. Over-the-counter cold products can also contain guaifenesin.

A nurse is teaching a client about ipratropium. Which of the following instructions should the nurse include?

A. Do not drink anything for 30 min after using the drug.

B. Wait 5 min between using the drug and another inhaled drug.

C. This drug is used to thin respiratory secretions.

D. Check pulse rate after inhaling the drug.

B. Wait 5 min between using the drug and another inhaled drug.

A nurse is teaching a client about albuterol. The nurse should instruct the client to monitor for and report which of the following as an adverse effect of this drug?

A. Fever

B. Bruising

C. Polyuria

D. Palpitations

D. Palpitations

A nurse is teaching a client about the adverse effects of pseudoephedrine. Which of the following should the nurse include? (Select all that apply.)

A. Restlessness

B. Bradycardia

C. Insomnia

D. Muscle pain

E. Anxiety

A. Restlessness

C. Insomnia

E. Anxiety

A nurse is teaching a client about ipratropium. The nurse should include that this drug has which of the following adverse effects? (Select all that apply.)

A. Muscle tremors

B. Increased intraocular pressure

C. Dry mouth

D. Insomnia

E. Tachycardia

B. Increased intraocular pressure

C. Dry mouth

A nurse is monitoring plasma drug levels in a client who is taking theophylline. Which of the following findings should the nurse expect to see if the client's drug level indicates toxicity?

A. Seizures

B. Constipation

C. Normal sinus rhythm

D. Somnolence

A. Seizures

A nurse is teaching a client who has a prescription for albuterol via inhaler and fluticasone via inhaler for asthma management. For which of the following reasons should the nurse instruct the client to use the albuterol inhaler before using the fluticasone inhaler?

A. Albuterol will increase the absorption of fluticasone.

B. Albuterol will decrease inflammation.

C. Albuterol will reduce nasal secretions.

D. Fluticasone will reduce the adverse effects of albuterol.

A. Albuterol will increase the absorption of fluticasone.

A nurse is preparing to administer phenylephrine to a client. The nurse should identify that which of the following manifestations is an adverse effect of this drug?

A. Hypertension

B. Sleepiness

C. Hypotension

D. Constipation

A. Hypertension

A nurse is teaching a client about the use of a mucolytic to treat a cough. The nurse should include that a mucolytic has which of the following therapeutic effects?

A. Suppresses the cough stimulus

B. Reduces inflammation

C. Thins and loosens mucus

D. Dries secretions

C. Thins and loosens mucus

A nurse should recognize that using pseudoephedrine to treat allergic rhinitis requires cautious use with clients who have which of the following conditions?

A. Peptic ulcer disease

B. A seizure disorder

C. Anemia

D. Coronary artery disease

D. Coronary artery disease

A nurse is teaching a client who is taking prednisone for an acute asthma exacerbation. Which of the following instructions should the nurse include?

A. "Avoid taking nonsteroidal anti-inflammatory drugs."

B. "Rinse your mouth after taking the medication to prevent a yeast infection."

C. "Stop taking the medication if you become nauseous."

D. "Change position slowly when standing up."

A. "Avoid taking nonsteroidal anti-inflammatory drugs."

Legal restrictions apply to the purchase of pseudoephedrine because of which of the following risks?

A. Respiratory depression

B. Drug abuse

C. Drug tolerance

D. Rebound congestion

B. Drug abuse

A nurse is caring for a client who is taking codeine. The nurse should identify that which of the following assessments is priority to make?

A. Blood pressure

B. Apical heart rate

C. Respirations

D. Level of consciousness

C. Respirations

A nurse is teaching a client about montelukast. Which of the following instructions should the nurse include?

A. Use a spacer to improve inhalation.

B. Take the drug at the onset of bronchospasm.

C. Rinse mouth to prevent an oral fungal infection.

D. Take the drug once a day in the evening.

D. Take the drug once a day in the evening.

A nurse is teaching a client about the use of antihistamines to treat allergic rhinitis. The nurse should explain that these drugs are effective because they perform which of the following actions?

A. Decrease viscosity of nasal secretions

B. Block H2 receptors

C. Prevent histamine from binding to receptors

D. Reduce nasal congestion

C. Prevent histamine from binding to receptors

A nurse is teaching a client about the use of beclomethasone to treat asthma. The nurse should explain that the drug has which of the following therapeutic effects?

A. Thins mucus

B. Relaxes bronchial smooth muscle

C. Decreases inflammation

D. Increases the cough threshold

C. Decreases inflammation

A nurse is teaching an adult client about diphenhydramine. The nurse should inform the client to expect which of the following adverse effects while taking this drug?

A. Muscle tremors

B. Drowsiness

C. Excitation

D. Insomnia

B. Drowsiness

A nurse is teaching a client about the use of cromolyn sodium to prevent bronchospasm. the nurse should explain that the drug has which of the following therapeutic effects?

A. Increases leukocyte activity

B. Blocks muscarinic receptors

C. Causes bronchodilation

D. Reduces inflammation

D. Reduces inflammation

Antitussives prototype

Dextromethorphan - non-opioid, codeine - opioid

Dextromethorphan Tx

Treatment of nonproductive cough

Dextromethorphan MOA

Work in the CNS to directly suppress the cough reflex in the medullary cough center, will also cause drying of mucus membranes

Dextromethorphan CI/C

• Pregnancy or breastfeeding

• Don't use if head injury or CNS depression (concussion or sedated etc.) since they work directly on the CNS

• Don't use with children under 4 years old - risk of CNS effects

• In men with BPH this drug can cause urinary retention

Dextromethorphan AE

• Oversedation, drowsiness, confusion, dizziness (CNS effects)

• drying effect (nausea, dry mouth, nasal irritation, constipation) - will need to drink water

• Tachycardia, HTN, restlessness

Dextromethorphan Teaching points

• Don't mix with alcohol

• Do not drive or operate heavy machinery while on medication

Dextromethorphan DI

Codeine and Hydrocodone are opiates so abuse potential exists along with rest of side effects - avoid ETOH!, MAOIs (can cause hypotension, fever, coma)

A way to remember Anticholernergic side effects

Can’t see, can't pee, can't spit, can't shit

Nebulizer

• Uses compressed air to change liquid drug into fine mist for inhalation

• If using hand-held device or mask sit upright or in a Semi-Fowler position

• Breathe slowly and deeply during treatment

• Rinse out mouth and clean device when treatment is over

Inhalers

• Wait at least 1 minute between inhalations of the same medications

• If 2 inhaled medications are prescribed, wait at least 5 minutes between medications

• spacer is used to hold the dose of the drug while the patient inhales

How to use Inhalers

1. Shake the canister

2. Exhale

3. Place the inhaler to mouth

4. Compress canister while inhaling

5. Hold breath as long as possible (a minimum of 10 seconds)

6. Exhale through pursed lips

Rescue and Maintenance Inhalers

Inhale the SABA before inhaling the glucocorticoid. The beta2 agonist promotes bronchodilation and enhances the absorption of the glucocorticoid

Mast Cell Stabilizers Prototype

Cromolyn

Cromolyn MOA

suppresses inflammation, does not cause bronchodilation. Effects less than steroids so not preferred drug for asthma but can be useful if issues tolerating steroids.

Cromolyn Therapeutic Use

used for prophylaxis in mild persistent asthma, exercise induced bronchospasm (EIB), intranasal can relieve allergic rhinitis

Cromolyn Teaching

Used for prevention of asthma exacerbation. May take several weeks to see therapeutic effects. Not to be used for emergent situations!

Topical Nasal Decongestants-Nasal Sympathomimetic Prototype

Oxymetazoline (Afrin)

Oxymetazoline (Afrin), Pseudoephedrine/phenylephrine AND Fluticasone (Flonase) MOA

Treatment of nasal/sinus congestion due to overproduction of mucus secretions - rhinitis, sinusitis, otitis

Oxymetazoline (Afrin) MOA

Causes vasoconstriction (activating the SNS receptors) in the nasal passages and sinuses - shrinks swollen mucous membranes and opens clogged passages. This works FAST (within minutes)

Oxymetazoline (Afrin) CI/C

Must check nares to make sure no lesions or erosions exist before administering

Oxymetazoline AE

Nose bleeds, irritation of the membranes, erosions (take a long time)

Oxymetazoline (Afrin) Teaching Points

• Proper technique needed to deliver medication - sit upright, hold down the opposite nostril when spraying medication

• may be aerosol (shake well) or spray

• Mimics the sympathetic nervous activity

  • So increased HR, BP, Resp, Agitation, CAUTION when underlying conditions are related to this activity (HTN, Anxiety, Arrythmia, Insomnia etc.)

• Should only use for 3-5 days before risking rebound congestion

Oxymetazoline DI

Cannot give it with cyclopropane or halothane (both anesthesia gasses) - major CV effects

Oral Decongestants-Oral Sympathomimetics Prototype

Pseudoephedrine, phenylephrine

You should only use Oxymetazoline (Afrin) for how long?

Should only use for 3-5 days

Pseudoephedrine, phenylephrine TX

Treatment of nasal/sinus congestion due to overproduction of mucus secretions - rhinitis, sinusitis, otitis

Pseudoephedrine MOA

SNS mimic (sympathomimetic) - causes vasoconstriction (activating the SNS receptors) in the nasal passages and sinuses - shrinks swollen mucous membranes and opens clogged passages

Pseudoephedrine AE

HTN, Anxiety, Insomnia, arrythmias

Oral Decongestants CI/C

• Caution with conditions that don't play well with the SNS - glaucoma, HTN, diabetes, thyroid disease, prostate problems, coronary artery disease (CAD)

• Caution in pregnancy - not really studied in pregnancy so risk vs reward here

Pseudoephedrine

This is a systemic medicine (whole body affected) so SNS effects are more likely and more annoying - tremor, anxiety, agitation, pallor, sweating, racing heart

Pseudoephedrine, phenylephrine Teaching Points:

Should only use for up to 7 days before risking rebound congestion (rebound vasodilation called rhinitis medicamentosa) - not for chronic rhinitis

Topical Nasal Steroid Prototype

Fluticasone (Flonase)

Fluticasone (Flonase) MOA

We are not sure but know that steroids have an anti-inflammatory effect - therapeutic effect is not immediate and may take up to **2-3 weeks to develop full therapeutic effect

Fluticasone (Flonase) AE

Very few- over-drying of the mucosa, headache. We like this medicine because it has very few systemic effects compared to oral steroids or antihistamines - great for pregnant/lactating women

Fluticasone (Flonase) Teaching Points

• Spray out towards nasal mucosa - not directly up nose

• Must use consistently to be effective and must have patience since effectiveness is delayed

• May cause local burning, irrigation, stinging, headache

• May put you at risk for infection

• Steroids lower immune response - so cannot give in the presence of an acute infection and must avoid airborne infections - notify provider if signs of infection

• Client can take non-NSAID analgesic like Tylenol if they experience headache

• **More effective than oral antihistamines for nasal and eye allergy symptoms

Expectorants Prototype

Guaifenesin (Mucinex)

Guaifenesin (Mucinex) TX

To help cough up thickened secretions in the respiratory tract - bronchitis, pneumonia, etc.

Guaifenesin (Mucinex) MOA

Thin out lower respiratory tract secretions by reducing surface tension making it easier to have a productive cough and clear airways. Increase production of respiratory secretions, which in turn decrease viscosity of mucous

Guaifenesin (Mucinex) CI/C

Clients with diabetes (sugar content)

Expectorants AE

GI symptoms - n/v/loss of appetite (anorexia)

Guaifenesin (Mucinex) Teaching Points

• Need to find the origin of the cough/thickened secretions as this med may mask symptoms - ****do not use longer than one week!

• Increase fluid intake to help expectorant liquify secretions

• This is the only expectorant on the market, so it shows up in many combination OTC meds to treat cold and flu symptoms - make sure to check what is in each so you don't take excessive doses

Short Acting Beta2 Agonists (SABAs)

• Albuterol, levalbuterol

• Used as needed in bronchospasm. 2 puffs inhaled q4h PRN.

• Used more frequently in acute bronchospasm. For exercise-induced bronchospasm 2 puffs inhaled x1 5-30 minutes before exercise.

Long Acting Beta2 Agonists (LABAs)

• Formoterol, salmeterol

• Used every 12 hours for long-term control and are not used to abort an asthma attack or exacerbation.

• Not used alone but are prescribed in combination with an inhaled glucocorticoid

Key points about Long-Acting Beta₂ Agonists (LABAs)

• Can increase risk of asthma-related death when used alone so typically paired with inhaled glucocorticoid or anticholinergic

• Only used when inhaled glucocorticoid has been inadequate by itself best used for long term control

• FDA recommends both drugs (inhaled LABA and glucocorticoid) be in the same inhaler

• Have a long term duration of action and are best used for long term control

Mucolytics Prototype

Acetylcysteine (Mucomyst)

Acetylcysteine (Mucomyst) Tx:

Increase or liquefy respiratory secretions to aid the clearing of the airways in high-risk respiratory patients who are coughing up thick, tenacious secretions. Patients may be suffering from conditions such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, pneumonia, or tuberculosis. Also used to treat Tylenol overdose

Acetylcysteine (Mucomyst) MOA:

Liquify lower respiratory tract secretions (break up the protein bonds in the mucous) making it easier to have a productive cough and clear airways

Acetylcysteine (Mucomyst) AE:

GI upset, rash, bronchospasm (because it is inhaled), rotten egg smell can induce nausea

Mucolytics CI/C

No data on pregnancy/lactation so caution

Acetylcysteine (Mucomyst) Teaching Points:

• Caution with acute bronchospasm, peptic ulcer, or esophageal varices (or active bleeding in the GI) - could make these things worse

• For high-risk respiratory patients, this medication is administered with a nebulizer (inhaled aerosol)

• Monitor respiratory status frequently (auscultation of lungs).

• Encourage to cough up secretions instead of swallowing them

• Have suction equipment available and help the client suction as needed

Leukotriene Receptor Antagonists - drugs that affect inflammation Prototype

montelukast, zafirlukast

montelukast, zafirlukast MOA

either block or antagonize receptors for the production of leukotrienes D4 and E4 - which are components of asthma

montelukast, zafirlukast CI/C

• caution in pts with hepatic or renal impairment

• fetal toxicity has been reported in animal studies, so use in pregnancy and lactation should benefit the mother more than it risks the fetus

• are not to be used for an emergency asthma attack - this is a maintenance drug

montelukast, zafirlukast AE

HA, dizziness, N, diarrhea, ABD pain, elevated liver enzymes (P-450 system) with zafirlukast, neuropsychiatric symptoms and suicidal ideation

montelukast, zafirlukast DI

phenobarbital, rifampin, and phenytoin may need higher doses of montelukast. Zafirlukast can increase levels of warfarin which could cause?

Oral steroids - drugs that affect INFLAMMATION Prototype

Prednisone

Prednisone MOA

suppress inflammation (prevent release of leukotrienes, prostaglandins, and histamine) decrease infiltration of inflammatory cells (eosinophils, leukocytes), decreased edema of airways

Prednisone CI/C

peptic ulcer disease, diabetes, HTN, renal dysfunction, or regular NSAID use. If client has systemic fungal infection or recently received a live virus vaccine avoid giving steroid

Prednisone AE

suppression of adrenal function, muscle wasting/bone demineralization, hyperglycemia, PUD, immunosuppression (will have increased risk for infection if on long term therapy), hypernatremia, hypokalemia

Prednisone Teaching

• Monitor plasma drug levels to determine the amount of adrenal function suppression.

• Observe for signs of infection that may not include fever or inflammation because these body responses are suppressed by steroids (sore throat, fatigue, tachycardia, wound discharge). Notify provider immediately

• For long term use (10 or more days) dose will need to be tapered due to potential for adrenal crisis

• Increase intake of calcium and vitamin D (to prevent osteoporosis)

• Report weight gain, edema, or generalized weakness - may indicate electrolyte imbalance

• Take gastric-protective measures to prevent ulcers (take PPI, avoid NSAIDs).

Predinisone DI

Furosemide (increased risk of hypokalemia), NSAIDS (increased risk of GIB), insulin and oral hypoglycemics effectiveness reduced while on steroids

Inhaled steroids - drugs that affect inflammation Prototype

Beclomethasone

Beclomethasone MOA

suppress inflammation (prevent release of leukotrienes, prostaglandins, and histamine) decrease infiltration of inflammatory cells (eosinophils, leukocytes), decreased edema of airways, used for long-term management of asthma or COPD

Beclomethasone CI/C

these medications should not ever be used for the treatment of an acute asthma attack or status asthmaticus; use with caution in active respiratory infection

Beclomethasone AE

• due to the route of administration; sore throat, hoarseness, coughing, dry mouth, and pharyngeal/laryngeal fungal infections, oral thrush (use spacer to decrease drug contact with mouth and oral pharynx)

• Inhaled steroids are beneficial because they have fewer systemic effects than oral steroids

Beclomethasone Teaching

• contact the MD if there are S/S of respiratory infection

• May take 2-3 weeks to reach effective levels

• To prevent thrush patient needs to wash out mouth well after use

Anticholinergics - another bronchodilator Prototype

ipratropium

ipratropium MOA

inhibits the action of acetylcholine at vagal-mediated receptor sites and relaxes smooth muscle leading to bronchodilation

ipratropium CI/C

caution in any condition that could be aggravated by anticholinergic effects (narrow angle glaucoma, bladder neck obstruction, or prostate hypertrophy)

ipratropium AE

dizziness, HA, fatigue, nervousness, dry mouth, sore throat, palpitations, and urinary retention

ipratropium DI

don't combine with any other anticholinergics

ipratropium teaching points

Fewer systemic effects than SABAS - not as effective so do not use in acute asthma exacerbation as a rescue drug

Short-Acting Beta₂ Agonists Prototype

albuterol, levalbuterol

Albuterol MOA

mimic the effects of the SNS; relaxes smooth muscle and dilates the bronchi, decreases wheezing, helps airways stay open!

Albuterol CI/C

• "these drugs are contraindicated or should be used with caution, depending on the severity of the underlying condition"

• including valvular disease, vascular disease, arrhythmias, diabetes, and hyperthyroidism - need to be monitored closely because of increase in SNS stimulation

• used in pregnancy and lactation only if the benefits to the mother outweigh the risks to the fetus/infant