ch 31

Introduction to Clinical Pharmacology

Chapter 31

Lower Respiratory System Drugs

Learning Objectives

Explain the uses, general drug actions, general adverse reactions, contraindications, precautions, and interactions of the bronchodilators and antiasthma drugs.

Distinguish important preadministration and ongoing assessment activities the nurse should perform on the client taking a bronchodilator or an antiasthma drug.

List nursing diagnoses particular to a client taking a bronchodilator or an antiasthma drug.

Examine ways to promote an optimal response to therapy, how to manage common adverse reactions, and important points to keep in mind when educating a client about the use of bronchodilators or antiasthma drugs.

Common Conditions of the Lower Respiratory System

COPD

Asthma

Chronic bronchitis

Chronic obstructive bronchitis

Emphysema

Lower respiratory tract infections

Asthma/Chronic Pulmonary Disorder Mediations

Long-Term Control Medications

Step-wise approach

Inhaled corticosteroids

Mast cell stabilizers

Leukotriene formation inhibitors

Leukotriene receptor agonists

Immunomodulators

Quick-Relief Medications

Inhaled short-acting beta2-adrenergic (β2-adrenergic) agonists (SABAs)

Oral steroids

Pharmacology in Practice Exercise #1

A client has been prescribed a step care approach regiment for the treatment of asthma. Which of the following drugs may be given as adjuncts to bronchodilator therapy in such a case? Select all that apply.

Decongestants

Inhaled corticosteroids

Uricosuric agents

Mast cell stabilizers

Immunomodulators

Adrenergic Bronchodilators—Actions and Uses

Actions

Simulates beta2-adrenergic receptors resulting in a relaxation of the smooth muscles and an opening of the bronchi or bronchodilation; relieves respiratory distress

Uses (Bronchoconstriction)

Bronchospasm associated with acute and chronic bronchial asthma

Exercise-induced bronchospasm

Bronchitis

Emphysema

Bronchiectasis

Other obstructive pulmonary diseases

Adrenergic Bronchodilators—Adverse Reactions #1

Cardiovascular System Reactions:

Tachycardia

Palpations

Cardiac arrhythmias

Hypertension

Adrenergic Bronchodilators—Adverse Reactions #2

Other Reactions:

Nervousness

Anxiety

Insomnia

Adrenergic Bronchodilators—Contraindications

Contraindicated in clients with:

known hypersensitivity to the drug

Cardiac arrhythmias associated with tachycardia

Organic brain damage

Cerebral arteriosclerosis

Narrow-angle glaucoma

Acute bronchospasm (salmeterol)

Adrenergic Bronchodilators—Precautions

Use cautiously in clients with:

hypertension

cardiac dysfunction

hyperthyroidism

glaucoma

diabetes

prostatic hypertrophy

history of seizures

pregnancy (Pregnancy category B and C)

lactation

Inhaled Steroids—Interactions #1

Inhaled Steroids—Interactions #2

Xanthine Derivative Bronchodilators—Actions and Uses

Actions

Stimulate the central nervous system to promote bronchodilation; cause direct relaxation of the smooth muscle to the bronchi

Uses

Symptomatic relief or prevention of bronchial asthma

Treatment of reversible bronchospasm associated with chronic bronchitis and emphysema

Xanthine Derivative Bronchodilators—Adverse Reactions #1

Central Nervous System Reactions:

Restlessness

Irritability

Headache

Nervousness

Tremors

Xanthine Derivative Bronchodilators—Adverse Reactions #2

Cardiovascular System Reactions:

Tachycardia

Palpations

ECG changes

Increased respirations

Xanthine Derivative Bronchodilators—Adverse Reactions #3

Other Reactions:

Nausea

Vomiting

Fever

Hyperglycemia

Flushing

Alopecia

Xanthine Derivative Bronchodilators—Contraindications

Contraindicated in clients with:

Known hypersensitivity to the drugs

Peptic ulcers

Seizure disorders

Serious uncontrolled arrhythmias

Xanthine Derivative Bronchodilators—Precautions

Use cautiously in clients with:

cardiac disease

hypoxemia

hypertension

congestive heart failure

liver disease

older adult

habitual alcohol use

pregnancy (pregnancy category C) and lactation

Xanthine Derivative Bronchodilators—Interactions #1

Xanthine Derivative Bronchodilators—Interactions #2

Xanthine Derivative Bronchodilators—Interactions #3

Xanthine Derivative Bronchodilators—Interactions #4

Xanthine Derivative Bronchodilators—Interactions #5

Pharmacology in Practice Exercise #2

A client was using a nicotine patch to stop smoking when they were started on theophylline for emphysema. After successfully stopping smoking and ready to stop using the nicotine patch, which of the following would be warranted?

Theophylline dose should be decreased

Theophylline dose should be discontinued

Theophylline dose should be increased

Theophylline dose should remain the same

Antiasthma-Specific Drugs: Inhaled Corticosteroids—Actions

Actions

given by inhalation and reduce airway hyperresponsiveness

Reduce the number of mast cells in the airway

Block reaction to allergens

Increase the sensitivity of the ẞ2 receptors; increased the effectiveness of ẞ2—receptor agonist drugs

Beclomethasone and flunisolide decrease inflammatory process directly in the airways

Antiasthma-Specific Drugs: Inhaled Corticosteroids—Uses

Uses

Management and prophylactic treatment of inflammation associated with asthma

Intranasal treatment of nasal polyps and rhinitis

Upper respiratory system conditions

Antiasthma-Specific Drugs: Inhaled Corticosteroids—Adverse Reactions

Respiratory System Reactions:

Throat irritation

Hoarseness

Upper respiratory tract infection

Fungal infection of the mouth and throat

Antiasthma-Specific Drugs: Inhaled Corticosteroids—Contraindications

Contraindicated in clients with:

known hypersensitivity to the drug

acute bronchospasm

status asthmaticus

other acute episodes of asthma

Antiasthma-Specific Drugs: Inhaled Corticosteroids—Precautions

Use cautiously in clients with:

compromised immune systems

glaucoma

kidney disease

liver disease

convulsive disorder

diabetes

pregnancy (pregnancy category B and C) and lactation

Antiasthma-Specific Drugs: Inhaled Corticosteroids—Interactions

Mast Cell Stabilizer—Actions and Uses

Actions

Thought to stabilize the mast cell membrane, possibly preventing calcium ions from entering mast cells; thus, preventing the release of inflammatory mediators such as histamine and leukotrienes

Uses

Treatment of asthma in combination with other drugs

Treatment of allergic rhinitis

To prevent exercise-induced bronchoconstriction

Mast Cell Stabilizer—Adverse Reactions

Respiratory System Reactions:

Throat irritation and dryness

Unpleasant taste sensation

Cough or wheeze

Can also cause nausea

Mast Cell Stabilizer—Contraindications and Precautions

Contraindicated in:

clients with known hypersensitivity to the drugs

acute asthma attacks

Use cautiously in:

pregnancy (pregnancy category B) and lactation

impaired renal or hepatic function

No significant interactions have been reported

Leukotriene Modifiers and Immunomodulators—Actions

Actions

Leukotrienes are primarily responsible for bronchoconstriction

Zileuton acts by decreasing the formation of leukotrienes

Montelukast and zafirlukast inhibit leukotriene receptor sites in the respiratory tract; prevent airway edema and facilitate bronchodilation

Omalizumab modulates the immune response by preventing binding of immunoglobulin to the receptors of basophils and mast cells; limits allergic reaction

Leukotriene Modifiers and Immunomodulators—Uses

Prophylaxis and treatment of chronic asthma in adults and children over the age of 12 years

Omalizumab is an adjunctive therapy for clients 12 years of age and older sensitive to allergens

Leukotriene Modifiers and Immunomodulators—Adverse Reactions

Headache

Flu-like symptoms

Immunoglobulators can cause anaphylactic reactions

Leukotriene Modifiers and Immunomodulators—Contraindications

Contraindicated in clients with:

known hypersensitivity to the drug

acute bronchospasm

liver disease (zileuton)

lactation

Use cautiously in clients with:

pregnancy (pregnancy category B and C)

Leukotriene Modifiers and Immunomodulators—Interactions

Nursing Process—Client Receiving a Lower Respiratory System Drug #1

Preadministration Assessment

Objective Data

Vital signs (including pulse oximetry)

Peak flow meter reading

Auscultate breath sounds

Description of sputum

Signs of hypoxia

Cyanosis of skin or mucous membranes

Laboratory tests: ABG, PFT

Nursing Process—Client Receiving a Lower Respiratory System Drug #2

Preadministration Assessment (continued)

Subjective Data

Type and duration of symptoms

Description of any environmental triggers

Description of activity disruption by symptoms

Health history (especially regarding seasonal allergies or allergens in household)

Remedies attempted before seeking care

Nursing Process—Client Receiving a Lower Respiratory System Drug #3

Ongoing Assessment—Acute Asthma Attack

Assess the respiratory status about 30 minutes after drug is administered and every 4 hours (or more often if needed) and whenever drug is administered

Focused respiratory assessment

Keep record of intake and output

Report any imbalance

After administration observe the client for the effectiveness of the drug

Nursing Process—Client Receiving a Lower Respiratory System Drug #4

Ongoing Assessment—Stable Chronic

Client self-monitors

Utilize asthma action plan to assess and treat appropriately

Nurse asks client about changes seen on the asthma action plan (i.e., have client’s status been in the green, yellow, or red zone)

Monitor for chest pain and changes in ECG in clients with a history of cardiovascular problems

Pulmonary function tests and comparison to baseline

Nursing Process—Client Receiving a Lower Respiratory System Drug #5

Nursing Diagnosis

Anxiety related to feelings of breathlessness

Ineffective Airway Clearance related to bronchospasm

Impaired Oral Mucous Membranes related to dryness or irritation

Malnutrition Risk: Less Than Body Requirements related to decreased appetite caused by nausea, heartburn, or unpleasant taste

Nursing Process—Client Receiving a Lower Respiratory System Drug #6

Planning

Expected client outcomes depend on the reason for administration of the drug but include:

Optimal response to therapy

Management of adverse drug reactions

Confidence in an understanding of the prescribed medication regimen

Nursing Process—Client Receiving a Lower Respiratory System Drug #7

Implementation

Promoting Optimal Response to Therapy

Careful monitoring of the client

Instruction on proper administration of various drugs

Nursing Process—Client Receiving a Lower Respiratory System Drug #8

Implementation

Promoting Optimal Response to Therapy

Quick Relief for Acute Symptom Intervention

Instruct client to administer 2 to 4 puffs of the inhaled SABA when acute distress occurs; up to 3 treatments in 20-minute intervals may be administered

Consider the use of nebulized drugs if metered dose inhaler is difficult to use or ineffective for the client

ICS and SABA—reduces inflammation and dilates bronchioles

Racemic epinephrine—to relieve croup symptoms in children

Antibiotics and mucolytics treat lung infections or loosen secretions of cystic fibrosis clients

Nursing Process—Client Receiving a Lower Respiratory System Drug #9

Implementation

Promoting Optimal Response to Therapy

Quick Relief for Acute Symptom Intervention (continued)

For a client in an urgent care or emergency care, epinephrine is administered subcutaneously for bronchospasm; minimize distractions while preparing; therapeutic effects last from 5 minutes to 4 hours

Rapid theophyllinization is sometimes indicated through loading doses given orally or IV over 12 to 24 hours

Monitor client closely for theophylline toxicity

Monitor IV site to monitor for extravasation

Nursing Process—Client Receiving a Lower Respiratory System Drug #10

Implementation

Promoting Optimal Response to Therapy

Long-Term Control of Symptoms

Teach the client to use the stepwise method of self-care created by the primary health care provider to control respiratory mucosal inflammation

Teach the client to refrain from swallowing the ICS’s and to rinse the mouth thoroughly after using the inhaler

When taking oral corticosteroids, children are at risk for growth reduction so monitor height and weight; older adults are at risk of osteoporosis so calcium and vitamin D supplements may be prescribed

Nursing Process—Client Receiving a Lower Respiratory System Drug #11

Implementation

Promoting Optimal Response to Therapy

Long-Term Control of Symptoms (continued)

Teach clients that formoterol comes in a capsule but is administered through an Aerolizer inhaler; do not take orally

Mast cell stabilizer cromolyn must be tapered if it is going to be discontinued; when administered orally, must be given 1.5 hours before meals and at bedtime.

Oral cromolyn comes in an ampule and is poured into water to administer (do not administer with other liquids)

Nursing Process—Client Receiving a Lower Respiratory System Drug #12

Implementation

Promoting Optimal Response to Therapy

Long-Term Control of Symptoms (continued)

Never administer leukotriene receptor antagonists, inhibitors, and immunomodulators during an acute asthma attack (given orally and can worsen the attack)

Before giving Zileuton and during therapy review hepatic aminotransferase levels for signs of liver dysfunction

Clients are monitored after the injection of mepolizumab (given once a month) in a clinic setting for the development of anaphylaxis; teach client the reaction can occur up to 4 days following the injection

Nursing Process—Client Receiving a Lower Respiratory System Drug #13

Implementation

Monitoring and Managing Client Needs

Anxiety

Reassure the client that the medications will help relieve difficulty with breathing

Speak and act in a calm manner

Closely monitor the client’s respiratory rate and blood pressure and report and significant changes

Nursing Process—Client Receiving a Lower Respiratory System Drug #14

Implementation

Monitoring and Managing Client Needs

Ineffective Airway Clearance

Check the blood, pressure, pulse, respiratory rate, pulse oximetry, and response to the drug every 5 to 15 minutes until the client’s condition stabilizes and respiratory distress is relieved

Nursing Process—Client Receiving a Lower Respiratory System Drug #15

Implementation

Monitoring and Managing Client Needs

Impaired Oral Mucous Membranes

Inhalers can cause infection with Candida albicans

Instruct client to use strict oral hygiene, cleans the inhaler, and use proper technique when taking the inhaled drug

Ensure the client brushes teeth daily after treatment

Nursing Process—Client Receiving a Lower Respiratory System Drug #16

Implementation

Monitoring and Managing Client Needs

Malnutrition: Less Than Body Requirements

Clients experiencing nausea as an adverse effect should be offered frequent small meals rather than three large meals

Meals should be followed by oral care

Limit fluids

Teach the client and family to have a clean relaxed atmosphere during meals

Nursing Process—Client Receiving a Lower Respiratory System Drug #17

Implementation

Monitoring and Managing Client Needs

Malnutrition: Less Than Body Requirements (continued)

Clients taking theophylline can experience heartburn

Instruct client to remain in an upright position and sleep with head of bed elevated

If the antiasthma drug creates a bad taste in the mouth, instruct the client to take frequent sips of water, suck on sugarless candy, or chew gum

Pharmacology in Practice Exercise #3

A client complains of nausea after receiving an antiasthma medication. Which of the following instructions should the nurse provide to alleviate the client’s symptoms? Select all that apply.

Keep the head of the bed elevated

Eat frequent small meals

Monitor blood pressure closely

Limit fluids with meals

Rinse mouth properly after eating

Nursing Process—Client Receiving a Lower Respiratory System Drug #18

Implementation—Educating the Client and Family

Nurse’s role is to instruct the client and family in:

methods to monitor the condition

control triggers in the environment

manage medications properly for optimal breathing

Nursing Process—Client Receiving a Lower Respiratory System Drug #19

Implementation—Educating the Client and Family

Teach the Client and Family:

To monitor breathing status and regulate medications based on the asthma action plan

How to use a peak flow meter and when to notify the primary health care provider

How to use an inhaler or nebulizer correctly and how to care for equipment

Nursing Process—Client Receiving a Lower Respiratory System Drug #20

Evaluation

Was the therapeutic effect achieved and cough relieved?

Were adverse reactions: identified, reported, and managed?

Anxiety is managed successfully

Client has a clear patent airway

Mucous membranes are moist and intact

Nutrition is adequately maintained

Did client and family express confidence and demonstrate understanding of drug regimen?

Turn and Talk—Case Study #1

A 27-year-old client has been diagnosed with asthma since the age of 8. They present to the physician’s office complaining of increased shortness of breath and coughing, especially at night, despite using an albuterol inhaler one or two inhalations every 4 to 6 hours as needed. The physician classifies the client’s asthma as Step 3 persistent.

What medications are recommended to treat the client’s asthma?

What environmental controls can the client use to help control the asthma?

Turn and Talk—Case Study #2

Before the client leaves the office, what should the nurse go over with them?