Resp. #1

Respiratory Drugs

Marissa H. Rafael, DNP, RNLearning Objectives

1. Review the pathophysiology of asthma and

COPD and the purpose of the medications.

2. Discuss the uses and effects of bronchodilators

and anti-inflammatory agents.

3. Differentiate between quick acting and long-

term control of asthma and chronic obstructive

pulmonary disease.

4. Discuss the mechanisms of action, indications,

adverse effects, drug interactions, and nursing

implications of corticosteroids.

5. Describe allergic rhinitis and medications to

manage symptoms.

6. Discuss the different types of medications used

for treatment of cough.Understanding Patho of Asthma & COPD

Asthma: REACTIVE

• Hyperresponsiveness of airways and bronchospasms

• Mast cells activated by allergens release histamine,

bradykinins, leukotrienes, and prostaglandins, causing

inflammation.

• This leads to bronchial muscle spasms, vascular

congestion, increased permeability, edema, and thick

mucus production.

COPD: OBSTRUCTIVE

• Emphysema and chronic bronchitis

• Chronic irritation damages alveoli and airways,

causing hyperinflation and loss of elastic recoil.

• Airway inflammation increases mucus production,

resulting in impaired gas exchange and air trapping.Understanding Patho of Asthma & COPD

Asthma: REACTIVE COPD: OBSTRUCTIVEClinical Manifestations

Asthma Symptoms COPD Symptoms

• Dyspnea

• Wheezing

• Chest constriction

• Increased HR

• Work to breathe

• Non-productive cough

• Dyspnea

• Hypoxemia

• Cough

• HypercapniaMedications for Asthma and COPD

ANTI-INFLAMMATORY

MEDS

S TEROIDS

Glucocorticoids/

Corticosteroids

• betamethasone (QVAR)

• Budenoside (Pulmicort)

• Flunisolide (Aerobid)

• Fluticasone (Flovent)

• Triamcinolone (Azmacort)

• Prednisone

• Prednisolone

L eukotriene Modifiers• Montelukast (Singulair)

M ast Cell Stabilizers• CromolynMedications for Asthma and COPD…

BRONCHODILATORS

B eta-2 Agonists• Albuterol (Proventil, Ventolin)*

• Bitolterol (Tomalate)

• Levalbuterol (Xopenex)

• Salmeterol (Serevent)*

• Formoterol (Foradil)

• Terbutaline (Brethine)

A nticholinergics

(Muscarinic Antagonists)

• Ipratropium (Atrovent, Combivent, Duoneb)

• Tiotropium (Spiriva)

M ethylxanthines• Theophylline (Theo-dur, Uniphyl)*

• Aminophylline (Truphylline)

• Oxtriphylline (Choledyl)

• Dyphylline (Dilor)Routes of Administration for meds for Asthma and COPD

Inhalation

• Metered Dose Inhalers

(MDI)

• Pump

• Can use spacer

• Dry-Powder Inhalers (DPI)

• Breath activated

• Nebulizers: Convert liquid

drugs to mist using

machines.

Oral (PO)

• Systemic effects and

is primarily used for

long-term control of

respiratory

conditions rather

than acute relief.

Parenteral

• Reserved for acute

relief situations

where rapid systemic

delivery is required

for immediate

therapeutic effect.Anti-Inflammatory Meds----SLM

S- STEROIDS

L- LEUKOTRIENE MODIFIERS

M- MAST CELL STABILIZERSAnti-Inflammatory Medications: CorticoSteroids

Mechanism of Action (MOA)• Inhaled (inh):

• Suppress inflammation of airways →

decreased bronchial hyperreactivity

• Decrease release of inflammatory mediators

• Decrease mucus production

• Increase number/sensitivity of Beta-2

receptors

• Oral (po):

• Suppress inflammation systemically →

decreased pain and swelling

• Suppress infiltration of phagocytes and

proliferation of lymphocytes → decreased

immune response

• Used short-term (5-7 days) with tapering.Anti-Inflammatory Medications: Corticosteroids

Types

• Inhaled (inh):

betamethasone (QVAR)

budenoside (Pulmicort)

Flunisolide (Aerobid)

Fluticasone (Flovent)

Triamcinolone (Azmacort)

• Oral (po):

Prednisone

PrednisoloneINHALED CORTICOSTEROIDS

INDICATIONS (IND):

• Prophylaxis

• Chronic asthma

• COPD

• Fixed schedule 2-4 puffs, 2x/day

• NOT FOR ACUTE ATTACKS

ADVERSE EFFECTS (AE):• Irritation of pharynx

• Oropharyngeal candidiasis (thrush)

• Dysphonia

• Longterm: adrenal suppressionLONG-TERM CORTICOSTEROIDS:

• When on long-term glucocorticoids, adrenal glands

decrease in the endogenous process of producing

glucocorticoids.

• If glucocorticoid therapy is stopped abruptly, it can

be dangerous and fatal

• Takeaway:

• when discontinuing a systemic glucocorticoid,

taper the dose. Gradually decrease the dose to

allow the body to produce the hormone.

• If someone is on glucocorticoids, and experiences

severe stress on their body (surgery, trauma,

illness), provider must be aware to prescribe

additional glucocorticoids to meet the needs of

the body

• Withdrawal scheduleORAL CORTICOSTEROIDS (prednisone)

INDICATIONS (IND):

• Short-term treatment of asthma and COPD exacerbation

• 5-7 days, taper

• Long-term Prophylaxis chronic asthma, COPD

• Autoimmune diseases:

• Rheumatoid arthritis

• Systemic lupus erythematosus (lupus)

• Inflammatory bowel disease

• Prevention of organ transplant rejection

• Cancer

• Skin disorders

• Allergic reactionsORAL CORTICOSTEROIDS

ADVERSE EFFECTS (AE):• Short-term

• Insomnia, nausea, mood swings

• Long-term

• Infection/immunosuppression

• Hyperglycemia

• Osteoporosis

• Adrenal suppression

• Fluid & electrolyte imbalances

• Peptic ulcer disease

• Growth suppression in children

• Cataracts, glaucoma

• Psychological disturbances

• Bruising

• Cushing syndromeCORTICOSTEROIDS

Contraindications (CI)

• Systemic fungal infections

• Vaccines

Drug Interactions (DI)• Meds that decrease Potassium (such as…)

• NSAIDs: increased risk for bleeding

• Insulin, oral hypoglycemic agents may be needed to

lower blood sugar

Nursing

• Taper dose

• Bleeding precautions

• Monitor blood sugar

• Longterm- Calcium and vit D

• Monitor K+ levelAnti-Inflammatory Medications:

Leukotriene Modifiers

• Reduces effects of leukotrienes

• Leukotrienes cause bronchoconstriction, increased

mucus, edema

Mechanism of Action (MOA)

• Leukotriene antagonist

IND

• Prevention and maintenance Chronic Asthma, COPD

• Prevention of exercise-induced bronchospasm

• Allergic rhinitis

AE

• Well-tolerated

Leukotriene Modifiers

Montelukast (Singulair) po

Max effects within

24 hours of first doseNOT FOR

QUICK RELIEF

Anti-Inflammatory Medications:

Mast Cell Stabilizers

• Non-steroidal anti-inflammatory agents

Mechanism of Action (MOA)

• Prevent the release of broncho-constrictive and

inflammatory substances from mast cells

• Cromolyn: stabilize cytoplasmic membrane of mast

cells → prevent release of histamine, others

• Chronic Asthma

• Exercise-induced asthma (neb)

• Safe, minimal adverse effects

IND

AE

Mast Cell Stabilizer

CromolynBRONCHODILATORS---BAM

B- BETA 2 AGONISTS

A- ANTICHOLINERGICS

M- METHYLXANTHINESBronchodilators: Beta-2 Agonists

1 Short-Acting (SABA) Inhaled-MDI

Albuterol (Proventil, Ventolin)*

Bitolterol (Tomalate)

Levalbuterol (Xopenex)

2 Long-Acting (LABA) Inhaled-MDI

Salmeterol (Serevent)*

Formoterol (Foradil)

3 Oral (not as common)

Albuterol (Proventil)

Terbutaline (Brethine)Bronchodilators: Beta-2 Agonists

1 Short-Acting Inhaled: Albuterol (Proventil, Ventolin)

MOA

• Activates beta-2 adrenergic receptors →

BRONCHODILATION

• Relieves bronchospasms

• Suppress histamine release

IND

• Inhaled:

• Acute bronchospasms

• Acute asthma

• COPD exacerbation

• Exercise-induced asthma prophylaxis

• Oral:

• Long-term control: not used aloneBronchodilators: Beta-2 Agonists

1 Short-Acting Inhaled (Albuterol)

Pharmacokinetics

• Inhaled

• FAST Onset < 5 minutes

• Peaks 30-60 minutes

• Duration 3-5 hours

• Dose: 1-2 puffs, 3-4 x/day

• Po

• 3-4 x/day

ADVERSE EFFECTS

• Increased HR

• Palpitations

• Angina

• Tremors

• More effects with poBronchodilators: Beta-2 Agonists

Long-Acting (LABA): Salmeterol (Serevent)

2

IND

• Prophylactic of acute asthma or COPD

• Long-term control, nocturnal asthma

Pharmacokinetics

• FIXED DOSE, not used by alone

• SLOWER Onset: 30 minutes

• Duration: 12 hours

ADVERSE EFFECTS

• Slight increase in HR

• TremorsBronchodilators: Anticholinergics/

Muscarinic Antagonists

• Block muscarinic receptors → bronchodilation

Short-Acting Long-Acting

Ipratropium

(Atrovent,

Combivent, Duoneb)

Tiotropium (Spiriva)Bronchodilators: Methylxanthines

• Relax bronchial smooth muscles

• Types

Theophylline (Uniphyl, Theo-dur)*

Aminophylline (Truphylline)

Oxtriphylline (Choledyl)

Dyphylline (Dilor)Bronchodilators: Anticholinergics/ Muscarinic Antagonists

Ipratropium (Atrovent)

• MOA blocks muscarinic receptors in the bronchi →

bronchodilation

• IND COPD

• Chronic asthma

• Exercise-induced asthma

• Pharmacokinetics

• Onset: < 5 minutes

• Duration: 6 hours

• Used alone or with beta-2 agonist

• 2 MDIs

• Combivent MDI

• Duoneb nebulizer

• AE dry mouth, irritation of pharynsBronchodilators: Methylxanthines

• Theophylline

• MOA • IND relax bronchial smooth muscle →

bronchodilation

• Decrease inflammation

• Increased ability of cilia to clear mucus

po: maintenance of chronic asthma 2-3x/day

IV: acute attacks, EMERGENCY

• SERUM LEVELS

NARROW THERAPEUTIC RANGE: 5-15 mcg/mLBronchodilators: Methylxanthines

• Theophylline

• AE at therapeutic levels: n/v, restlessness,

insomnia

at toxic levels: dysrhythmias, seizures,

cardiorespiratory collapse

• DI P450 substrate

• Caffeine (mimics): increased levels of

theophylline

• Smoking: induce theophylline metabolism

• Phenobarbital, Phenytoin (dilantin):

• Induce theophylline metabolism

• Cimetidine (Tagamet)

• Inhibit theophylline metabolism→ high

levelsCombination medications

Advair (Fluticasone + salmeterol)

[glucocorticoid + beta-2 agonist/LABA)Asthma Management

• Mild intermittent -PRN short-acting beta-2 agonist

• Mild persistent -low-dose inhaled corticosteroid

-PRN short-acting beta-2 agonist

• Moderate -low-dose inhaled corticosteroid and

long-acting inhaled beta-2 agonist

• Severe OR

-medium-dosed inhaled corticosteroid

-PRN short-acting beta-2 agonist

-high-dose inhaled corticosteroid and

long-acting inhaled beta-2 agonist

-Oral corticosteroid

-PRN short-acting beta-2 agonistAllergic Rhinitis Management

Inflammatory disorder affecting upper/lower airways, and eyes. Caused by allergen

binding to immunoglobulin E antibodies on mast cells → release of inflammatory

mediators (histamine, leukotrienes, prostaglandins)

Intranasal Glucocorticoids Intranasal Mast Cell Stabilizers

Beclomethasone (Beconase)

Cromolyn (Nasalcrom)

Budenoside (Rhinocort)

Fluticasone (flonase)

Triamcinolone (Nasocort)

MOA: suppresses mediator release from mast cells.

Used regularly prophylactically, 1 spray MDI per

nostril 4-6x daily.

Antihistamines Decongestants

Diphenhydramine (Benadryl)

Chlorphemiramine (Chlor-trimeton)

Oxymetazoline (Aprin 12 hr) spray/drops

Phenylephrine (Neo-synephrine) spray/drops/po

Desloratadine (Clarinex)

Pseudoephedrine (Sudafed) po

Fexofenadine (Allegra)

Naphazoline (Privine) spray/drops

Loratadine (Claritin)

Cetirizine (Zyrtec)Allergic Rhinitis Management:

Intranasal Glucocorticoids

Beclomethasone (Beconase)

Budenoside (Rhinocort)

Fluticasone (flonase)

Triamcinolone (Nasocort)

Intranasal Glucocorticoids• MOA

• Decrease inflammation of nasal

passages

• Regular schedule during allergy

season

• 1 spray/nostril, 1-2 x/day

• AE

• Dry nasal mucosa

• Sore throat

• Headache (HA)

• Burning, itching nose

• EpistaxisAllergic Rhinitis Management: Antihistamines

Antihistamines

• MOA: histamine antagonist,

block histamine receptors (H1)

• IND: allergic rhinitis

motion sickness

insomnia

• AE: sedation (1st gen)

dry mouth

urinary hesitancy

constipation

nausea

• DI: any CNS depressant

alcohol

1st generation

• Chlorphemiramine (Chlor-trimeton)

• Diphenhydramine (Benadryl)

2nd generation

• Desloratadine (Clarinex)

• Fexofenadine (Allegra)

• Loratadine (Claritin)

• Cetirizine (Zyrtec)Allergic Rhinitis Management: Decongestants

• MOA: activate alpha-1 adrenergic receptors on blood vessels→

vasoconstriction →

shrinks swollen membranes →

nasal drainage and decrease congestion

• IND: allergic rhinitis

cold, sinusitis

• AE:

• Spray

• Rebound congestion

• PO

• CNS stimulation

• CV effects

• Potential for abuse

Decongestants

Oxymetazoline (Aprin 12 hr) spray/drops

Phenylephrine (Neo-synephrine) spray/drops/po

Pseudoephedrine (Sudafed) po

Naphazoline (Privine) spray/dropsCough Management Medications

Expectorants

Antitussives

• Opioid

Guaifenesin

(Robitussin, Mucinex)

Codeine

Mucolytics

Hydrocodone

• Non-opioid

Acetylcysteine (Mucomyst)

Dextromorphan

Benzonatate

(Tessalon)Cough Management Medications:

Opioid Anti-tussives

Antitussives

Cough Suppressants

• Opioid

Codeine

Hydrocodone

• MOA:

• Act in CNS to elevate cough

threshold →

decreased frequency and

intensity of cough

• Adverse effects

• Respiratory depression

• Potential for abuseCough Management Medications: Dextromorphan

Antitussives

Cough Suppressants

• Non-opioid

• MOA:

• Act in CNS to elevate cough

threshold

• Adverse effects

• Minimal

DextromorphanCough Management Medications: Benzonatate

• MOA:

Antitussives

Cough Suppressants

• Non-opioid

• Decrease sensitivity of stretch

receptors in respiratory tract

• Adverse effects

• Dizziness

• Sedation

• do not chew

Benzonatate

(Tessalon)

• SWALLOW WHOLE

• If chew, severe bronchospasm

and rapid numbing-

aspiration/chokingCough Management Medications

• MOA:

• Stimulate the flow of

respiratory tract secretions→

more productive cough

• Thin and mobilize mucus

• Adverse effects

Expectorants

Guaifenesin

(Robitussin, Mucinex)Cough Management Medications: Mucolytics

• MOA:

• Reacts directly with mucus to make it

more watery→easier to expectorate

• Route: inhalation for direct airway

effect

• Adverse effects

Mucolytics

Acetylcysteine (Mucomyst)Key Clinical Considerations

Monitoring Requirements

Theophylline requires serum level

monitoring (5-15 mcg/ml).

Oral glucocorticoids need gradual

tapering to prevent adrenal

insufficiency.

Long-term steroid use requires

monitoring for infections,

hyperglycemia, and osteoporosis.

Patient Education

Proper inhaler technique is crucial for

medication effectiveness.

Rinse mouth after inhaled

corticosteroids to prevent oral

candidiasis.

Recognize signs of respiratory

distress requiring immediate medical

attention.

Drug Interactions

Theophylline interacts with caffeine,

smoking, phenobarbital, and

cimetidine.

Oral steroids interact with NSAIDs

and diabetes medications.

CNS depressants potentiate

antihistamine sedation effects.