Pharmacology – Respiratory Drugs

beta 2 adrenergic bronchodilators (front door bronchodilators)
– short acting beta 2 agonists SABA
rescue/ quick relief medications
indicated for treatment of acute episodes of bronchospasm
-albuterol (ventolin or Proventil) = dose 2.5 mg in 3 ml NS Q1-Q6 hours
-levalbuterol (xopenex)

beta 2 adrenergic bronchodilators (front door bronchodilators)
– long acting beta 2 agonists LABA
maintenance/ long term control medications
indicated for long term control of bronchospasm in patients with asthma and COPD
taken twice a day to control symptoms
should not be used for acute episodes of bronchospasm
-salmeterol (serevent)
-formoterol (foradil)
-arformoterol (brovana)

beta 2 adrenergic bronchodilators (front door bronchodilators)
– side effects and hazards of beta adrenergic bronchodilators
-tremors, shakes, quivering (most common)
-palpitations (feeling of heart activity of the patient)
-hypertension/ hypotension
-paradoxical hypoxemia
-tachyphylaxis (lack of response to normal drug action over time)
-nausea/ vomiting

**if any occur, stop therapy, notify nurse/ physician, and document
**if bronchospasm/ wheezing persists = first increase dosage to maximum, then increase frequency

anticholinergics / parasympatholytics (back door bronchodilators)
these drugs work against the bronchoconstriction caused by the parasympathetic nervous system (decrease cyclic GMP)
act by blocking cholinergic parasympathetic receptors
these anticholinergic bronchodilators can be given with short acting beta 2 adrenergic SABA bronchodilators for persistent bronchospasm
-ipratropium bromide (atrovent)
-tiotropium bromide (spirivia)
-oxitropium bromide (oxivent)

methylxanthines / phosphodiesterase inhibitors (side door bronchodilators)
this inhibitor drug indirectly increases the amount of cAMP within smooth muscle
the increased level of cAMP causes bronchodilation
safe therapeutic blood level of theophylline is – mcg/ml to optimize bronchodilation
blood levels are important to monitor in patients receiving methylxanthine drugs
theophylline is also given to increase diaphragmatic contractility and stimulate the CNS in infants with apnea of prematurity
serum levels are kept at – mcg/ml in neonates and children
-theophylline (aminophylline)
-oxtriphylline (choledyl)

anti-inflammatory agents with direct and indirect bronchodilating effects
steroids are indicated for patients with asthma and COPD
-fluticasone (flovent)
-beclomethasone (beclovent, vanceril, qvar)
-budesonide (pulmicort)
-flunisolide (aerobid)
-triamcinolone (azmacort)
-methylprednisolone (solu-Medrol)

– side effects and hazards
may be severe
include: adrenal suppression, cushing’s syndrome, hypertension and oral candidiasis/ thrush for inhaled aerosols (thrush can be treated with anti fungal agents = nystatin)

combining medication
– adrenergic + anticholinergic agents
-ipratropium bromide and albuterol (combivent, duoneb)
more control of bronchospasm
reduced drug dosages
avoidance of steroids

combining medication
– anti-inflammatory + long acting bronchodilator
-advair (fluticasone (anti-inflammatory) and formoterol (long acting bronchodilator))
indicated for patients with asthma ( 12 years and older) and COPD
medication should be taken twice a day
not recommended for treatment of acute bronchospasm

if patient is receiving multiple inhaled medications, administer in this sequence:
-bronchodilator and/or anticholinergic (albuterol and/or ipratropium bromide)
-corticosteroid (fluticasone)
-antibiotics (tobramycin)

mucolytic agents may be recommended when secretions are thick and tenacious (inspissated) and cannot be easily removed
-acetylcysteine (mucomyst) = dissolves disulfide bonds; indicated to liquefy thick tenacious secretions and to treat acetaminophen overdose; most common side effect is bronchospasm; patients should always receive a bronchodilator prior to this med
-recombinant human DNAse (pulomozyme) = specifically indicated for patients with CF; side effects include: voice alteration, pharyngitis, laryngitis, rash, chest pain, and conjunctivitis

pulmonary vasodilators
specifically dilate the pulmonary blood vessels
indications: pulmonary hypertension, ARDS, and right ventricular failure/ cor pulmonale
-prostacyclins = epoprostenol (flolan)
-lloprost (ventavis)
-sildenafil (Viagra. revatio)

wetting agents
the main use of these substances are to liquefy secretions and as diluent for medications
water given orally or intravenously is the best mucolytic
sterile distilled water aerosol is very irritating to airways and may cause bronchospasm
saline solutions:
-0.45% saline = hypotonic saline; for liquefying secretions and humidifying the airway, may be irritating and can cause swelling or dried retained secretions or bronchospasm
-0.9% saline = isotonic/normal saline; commonly used to liquefy secretions, to humidify the airway and as a diluent for medication
-1.8-15% saline = hypertonic saline; commonly used to induce sputum specimen, can irritate the airway and cause bronchospasm or secretion obstruction

leukotriene modifiers
non-steroid drugs that have been approved for patients with mild to moderate persistent asthma
not to be used for treatment of acute asthma attacks
improve lung function, reduce symptoms, and the need for beta agonist drugs
-montelukast (singulair)
-zafirlukast (accolade)
-zileuton (zyflo)

mast cell stabilizers
these drugs will help prevent an asthma attack by inhibiting the degranulation of the mast cells and preventing the release of histamine and leukotrienes
recommended for patients with exercise induced asthma EIA or exercise induced bronchospasm EIB
these drugs are not effective once the asthma attack has begun
-cromolyn sodium (intal, aarane)
-nedocromil sodium (tilade)

mucosal vasoconstrictors/ decongestants
cause vasoconstriction to reduce blood flow and mucosal edema
indications include upper airway conditions such as croup and pot extubation swelling were mild/ moderate stridor is present
-aerosolized racemic epinephrine (vaponefrin)

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