Pharmacology Notes

Intranasal Steroids

• Reduce inflammation (swelling, tenderness) in tissues.

• Examples: Fluticasone, Beclomethasone, Dexamethasone, Mometasone

• Side effects:

  • Local, not systemic.

  • Unlikely to cause systemic side effects.

  • Allergic rhinitis: Decreases inflammation and swelling to improve airflow.

  • Severe inflammation may require stronger steroids (oral).

Adverse Effects

• Epistaxis (nosebleeds):

  • Caused by drying of the nasal mucosa.

  • More common in elderly people, especially in dry environments.

  • Advise using a humidifier.

• Oral candidiasis (thrush):

  • Yeast infection (Candida) in the mouth.

  • Steroids decrease the immune system, allowing yeast to thrive.

  • Distinguish from lesions by cleaning with gauze; thrush is cleanable.

• Rebound condition:

  • May occur after short-term use.

Long-Term Steroid Use

• Common side effects:

  • Osteoporosis (calcium loss from bones).

  • Immunosuppression (increased risk of infections).

  • Hyperglycemia (high blood sugar).

  • Muscle wasting.

• Steroids are not ideal for flare-ups:

  • Work slowly.

  • Decongestants are preferred for quick relief.

Bronchodilators and Steroids

• Administer bronchodilators before steroids.

  • Opens airways for better steroid absorption.

• General rule: Give medications that create space first.

Long-Term Steroid Use Considerations

• Adrenal gland suppression:

  • Long-term steroid use suppresses natural steroid production.

  • Abruptly stopping steroids can cause adrenal crisis.

  • Taper steroids gradually to allow adrenal gland to recover.

• Hormone considerations:

  • Similar tapering needed for thyroid medications.

  • Avoid abrupt cessation of hormone replacement therapies.

Intranasal Steroids Summary

• Use: Inflammation in the nose.

• Common side effect: Epistaxis.

• Oral administration: Swish and swallow.

Lower Respiratory Tract Anatomy

• Larynx: Voice box.

• Trachea: Windpipe, splits into right and left bronchi.

• Carina: Point where trachea splits; important for suctioning.

Bronchi and Lungs

• Bronchi: Airway passage (no gas exchange).

• Right lung: Three lobes.

• Left lung: Two lobes.

• Bronchioles: Smaller branches of bronchi connecting to alveoli.

• Alveoli: Small sacs for gas exchange (oxygen and carbon dioxide).

• Pleura: Two sacs surrounding the lungs (visceral and parietal).

  • Inflammation or fluid buildup can compress the lungs.

Alveoli and Gas Exchange

• Hypoxia: Low oxygen due to impaired gas exchange in alveoli.

• Perfusion: Blood flow around alveoli needed for gas exchange.

• Upper vs. Lower Respiratory Issues:

  • Upper: No gas exchange problems.

  • Lower: Gas exchange impaired.

Alveoli Function

• Inflate upon inhalation, deflate upon exhalation.

• Walls never fully touch to prevent collapse.

• Surfactant: Substance preventing alveolar collapse (especially important in newborns).

Respiratory Diseases

• COPD (Chronic Obstructive Pulmonary Disease):

  • Progressive and irreversible.

  • Treatable but not curable.

  • Common in smokers.

• Asthma:

  • Hypersensitivity leading to airway constriction.

  • Can be mild or severe; severe cases classified under COPD.

• COPD Umbrella:

  • Severe asthma cases.

  • Chronic bronchitis: Inflammation of bronchi.

  • Emphysema: Alveoli damage (common in smokers).

• Pneumonia:

  • Infection, not COPD.

• COPD Lung Remodeling:

  • Tissue changes.

  • Drive to breathe shifts to lack of oxygen rather than excess carbon dioxide.

Asthma

• Triggers cause airway constriction, inflammation, and mucus production.

• Airway narrowing restricts airflow.

Bronchitis

• Inflammation and mucus excess.

• Acute or chronic (chronic is classified as COPD).

Emphysema

• Alveoli destruction, reducing gas exchange.

• Blood diverted away from damaged alveoli.

• Hypoxia expected.

Atelectasis

• Collapsed alveoli.

• Prevented with incentive spirometers after surgery.

Pneumonia

• Bacterial infection with pus/mucus accumulation in alveoli.

• Hypoxia expected.

Cystic Fibrosis

• Excessive mucus production.

• Requires chest physiotherapy.

• Life-shortening.

Pulmonary Fibrosis

• Normal tissue replaced by connective tissue (scarring).

• Impairs function.

ABGs (Arterial Blood Gases)

• pH scale: 0-14 (7 is neutral).

• Blood pH range: Very narrow.

• Key players in pH balance:

  • Carbon dioxide (acidic).

  • Bicarbonate (base).

Acid-Base Balance

• Vomiting (losing acid): Leads to alkalosis; body slows breathing to retain carbon dioxide.

• Diarrhea (losing base): Leads to acidosis; body increases respirations to expel carbon dioxide.

Treatment Strategies

• Lower respiratory issues:

  • Cough is a symptom, not the primary issue.

• Asthma:

  • Control to prevent attacks.

  • Avoid emergency room visits.

  • Goal: control, avoid side effects.

• COPD:

  • Maintenance, improve quality of life.

  • Long-term systemic corticosteroids avoided.

• Medications:

  • Expectorants, antitussives, mucolytics (acetylcysteine).

  • Bronchodilators (albuterol, salmeterol).

Bronchodilators

• Dilate constricted bronchioles.

• Albuterol:

  • Rescue drug, short-acting (4 hours).

• Salmeterol:

  • Maintenance, long-acting.

• Ipratropium/Tiotropium (Anticholinergics):

  • Ipratropium: Also bronchodilator, dries secretions.

  • Used for anticholinergic properties.
    ** Anticholinergic side effects: "Can't see, can't spit, can't poop, can't pee."

• Theophylline:

  • Old-fashioned, narrow therapeutic range, many side effects.

  • Used in emergencies or when other medications fail.

• Beta-2 Agonists (Albuterol, Salmeterol):

  • Stimulate beta receptors to dilate bronchi.
    ** Side Effects: Tachycardia, tremors, insomnia.
    Palpitations: Unpleasant awareness of heartbeats.

Beta-2 Agonists

• Albuterol: short-acting, rescue drug

• Salmeterol: long-acting, maintenance

• Side Effects

  • Tachycardia, Tremors and Insomnia.

Ipratropium

Fast acting agent like albuterol. Frequently given together with albuterol for an attack: give albuterol first.

Teotropium

Maintenance (e.g.,spiriva) - must take even when not having an attack.
Taken daily.

Functioning

Blocks Parasympha system from constricting.

SIDE EFFECTS:

Anticholinergic - Dry Airway (helps if secretions present).

Considerations

Causes urinary retention, be mindful about patients with enlarged prostate.

MDIs - Medical Dose Inhalers (Shake first!). Inhale, Exhale, then press release into mouth, Hold for 10 seconds, and then breathe again. Wait 1 minute before a second puff if needed.

Home Considerations With Asthma

Give albuterol first in rescue situations. Epinephrine could be considered.
Avoid if possible: Levothyroxine and Terbutaline.

Steps If Asthma Attack Appears:

1. Give bronchodilator

2. Can be given in combination, Epotopium is a secretion drying agent (also bronchodilator).

3. Steroids IV will assist with in decreasing inflammation.

Other Medication Considerations

• Salmeterol is long term, if albuterol does not resolve problems consider more maintenance medication.
  Anticholergics like ipratopium have some rescue aspects. These are given with nebulizers or through liquid inhalation.
  It's very important to rinse and ensure teeth are clean for any maintenance to avoid thrust.

Steroids (End in Sone or Ide)

Primarily anti-inflammatory medications that effect the entire body. Also increase sensitivy to bronchodilators.

**Side Effects:
Muscle wasting, Osteoporosis, Hyperglycemia.

Important Points

• If on long term, give in morning.

• Monitor:

• Weight

• Sleep

• Blood GLucose Level.

Rinse after use!

Leukotrines (Maintenance)

Leukotrins cause constrictions so Blocking these will prevent constrictions. Side effect is that it causes Phych issues leading to suicidal ideations.

Chromolyne

Also given for asthma, and comes over the counter. Decreases histamine.