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Chapter 14
The Respiratory System and
Drug Therapy
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Chapter 14
Topics
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Anatomy and Physiology of the Respiratory System
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Pneumonia and Tuberculosis (TB)
Cystic Fibrosis
Smoking Cessation
Herbal and Alternative Therapies
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Anatomy and Physiology of the Respiratory System
Regions of the Respiratory Tract
• The respiratory tract has an upper region and a lower
region
 Upper Respiratory Tract: nasal passages, sinuses, and
the throat area
 Epiglottis and larynx (voice box) are in the upper
throat
 Lower Respiratory Tract: bronchi, bronchioles, lungs,
and alveoli
• Because different diseases and conditions affect each
region, different drug therapies are prescribed
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Anatomy and Physiology of the Respiratory System
Upper and
Lower
Respiratory
Tracts
• The epiglottis
divides the
upper and
lower
respiratory
tracts
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Anatomy and Physiology of the Respiratory System
The Process of Breathing
• When a person breathes, air is pulled into and pushed out
of the lungs
• In the lungs, small air sacs (alveoli) fill with air and allow
for gas exchange with the blood
 Alveoli’s large surface area and number of blood vessels
allow oxygen to move into the blood and carbon
dioxide (a by-product of cellular function) to leave the
blood
 This process is called the gas-exchange process
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Anatomy and Physiology of the Respiratory System
The Gas-Exchange Process
• Involves two actions
 Oxygen is picked up in the lungs and is carried by red
blood cells to all the cells of the body
 Carbon dioxide is brought back to the lungs to be
expelled during exhalation
• Serves two functions
 Provides oxygen to body cells to supply energy and to
fuel cellular respiration
 Helps maintain acid/base balance in blood; keeps blood
pH within safe limits
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Anatomy and Physiology of the Respiratory System
The Gas-Exchange Process (continued)
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Asthma
About Asthma
• Affects over 22 million people in the U.S.—6 million of
which are children—and is on the rise
• Accounts for many ER visits, hospitalizations, and deaths
• The primary goals of treatment
 Reduce acute and chronic symptoms
 Prevent exacerbations
 Minimize hospitalizations or visits to the ER
• Other goals of treatment
 Improve quality of sleep
 Allow for increased patient activity
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Asthma
About Asthma (continued)
• Asthma is an inflammatory disorder of the airways in
which bronchioles constrict, mucus increases, and lung
tissue swells
 Chronic (not curable) condition; can be reversible in
that it can improve or be controlled with medications
 Episodic condition: times of poor airflow and difficulty
breathing alternate with times of normal function
• Symptoms: coughing, wheezing, breathlessness, and chest
tightness
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Asthma
Asthmatic Lung
• A lung with asthma
“overreacts” to
produce excess
mucus and swelling
• The combination of
excess mucus and
bronchoconstriction
makes airflow
difficult
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Asthma
Asthma Attacks
• Characterized by hyperreactivity of the airways
• Triggers (common): smoke, dust, exercise, pet dander, cold
weather, colds, flu
• Triggers (other): medicines, anxiety, laughing, some foods
• Immediately after exposure to a trigger, mast cells in lung
tissue release histamine and other chemical mediators
 Causes bronchospasm and increased mucus production
• Drug treatment can help control airway constriction and
breathing symptoms
 Without treatment, lung function declines
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Asthma
Assessment and Treatment of Asthma
• Categorized into levels of severity: intermittent, mild,
moderate, and severe
 Categories are based on how symptoms affect sleep,
normal daily activities, and breathing ability
• Pulmonary function tests used to assess asthma severity
• Rescue treatment is used once symptoms have begun
• Long-term drug therapy prevents exacerbations, improves
lung function, and decreases the need for short-term
relief therapies
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Asthma
Monitoring of Lung Function
• Patients can monitor their lung function at home with a
small, portable peak flow meter (sold in most pharmacies)
 It measures the strength of airflow exiting the lungs
 When patients chart their results daily, they can see if
their lung function is declining over time
 If so, they can work with their healthcare providers
• Technicians can suggest that patients using multiple
inhalers for asthma also use a peak flow meter regularly
 Pharmacists can offer instruction for proper use
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Asthma
Drugs for Asthma
• Asthma management generally begins with inhalers and
proceeds to oral therapies
• Short-term drug therapy
 Rescue inhalers for quick relief during an asthma attack
 Short-acting beta agonists (with or without an inhaled
corticosteroid)
• Long-term drug therapy
 Inhaled corticosteroids as anti-inflammatory agents
 Leukotriene inhibitors or mast cell inhibitors to improve
bronchoconstriction
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Asthma
Drugs for Asthma: Methods of Drug Delivery
• MDI
 Used most often to deliver beta agonist agents and
inhaled corticosteroids
 Used with a spacer that improves drug delivery
 Spacer briefly suspends medication mist in the air
• Dry powder inhaler
 Contains dry powder that is inhaled into the lungs
• Nebulizer machine
 Creates a fine mist that is inhaled through a mask
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Asthma
Drugs for Asthma: Short-Acting Beta Agonists
• Indications (inhalation): short-term relief of breathing
symptoms related to asthma; sometimes used for COPD
• Mechanism of Action: stimulate beta-2 receptors in lungs
and produce smooth muscle relaxation in bronchioles
• Side Effects (common): dizziness, nervousness, heartburn,
nausea, tremors
• Side Effects (other): increased BP, heart palpitations
• Cautions: interact with digoxin and can cause toxicity;
should not be used with beta blockers
• Caution: Shake MDIs before each use
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Asthma
Drugs for Asthma: Inhaled Corticosteroids
• Indication (inhalation): long-term treatment and control of
moderate to severe asthma; sometimes used for COPD
 Purpose: prevent frequent asthma attacks
• Indication (oral): short-term therapy only
• Mechanism of Action: decrease inflammation causing
bronchoconstriction and excess mucus production
• Side Effects (common): dry mouth, headache, sore throat,
hoarseness, coughing, oral fungal infection (oral thrush)
• Cautions: shake MDIs before each use;
do not shake dry powder inhalers before use
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Asthma
Drugs for Asthma: Leukotriene Inhibitors
• Indications (inhalation): long-term control of moderate to
severe asthma; allergic rhinitis
 Often prescribed when short-acting beta agonists and
inhaled corticosteroids are not controlling symptoms
 May be limited to specific ages of children
• Mechanism of Action: zileuton inhibits leukotriene
synthesis; zafirlukast and montelukast are leukotriene
receptor blockers
• Side Effects (common): nausea, sore throat, sinusitis
• Caution: contraindicated in patients with liver problems
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Chronic Obstructive Pulmonary Disease (COPD)
About COPD
• Fourth leading cause of chronic disease and death
in U.S.; most people with COPD are smokers
• Chronic and progressive disease that is not reversible;
airflow is limited by an abnormal inflammatory response
• Two sets of symptoms: chronic bronchitis and emphysema
 Chronic bronchitis: a persistent cough producing
sputum for 3+ months for at least 2 consecutive years
 Emphysema: fast, labored breathing that results from
damaged or destroyed alveolar walls
 Impaired walls reduce lung surface area
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Chronic Obstructive Pulmonary Disease (COPD)
Drugs for COPD
• Drug therapy
 Relieves symptoms
 Improves quality of life
 Allows increased patient activity
• Indications (most agents): bronchoconstriction that occurs
as the condition gets worse
• Indication (portable oxygen): most severe states of COPD
 Technicians do not typically dispense oxygen
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Chronic Obstructive Pulmonary Disease (COPD)
Drugs for COPD: Anticholinergics
• Indication: first-line treatment for bronchoconstriction
• Mechanism of Action: inhibit ACh (neurotransmitter that
causes smooth muscles in the lungs to constrict)
• Routes: all are inhalation; ipratropium is also intranasal
• Side Effects (common): dry mouth, nervousness, dizziness,
headache, cough, nausea, nasal dryness, upper RTI
• Cautions: contraindicated in patients with glaucoma,
urination problems, or soy or peanut allergies
• Cautions: ipratropium inhalers need primed before first
use; tiotropium capsules are inhaled (not swallowed)
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Your Turn
Question 1: At times, a patient has chest tightness and wheezes
and coughs. He is diagnosed with asthma. What drug therapy is
likely to be prescribed?
Answer: Asthma management generally begins with inhalers.
Typically, short-acting beta agonists (with or without an
inhaled corticosteroid) are the first treatment.
Question 2: What is a restriction of anticholinergics, the first-line
treatment for bronchoconstriction from COPD?
Answer: Patients should not take these agents if they are
allergic to peanuts or soy or have glaucoma or urination
problems.
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Chronic Obstructive Pulmonary Disease (COPD)
Drugs for COPD: Long-Acting Beta Agonists
• Indications: COPD; also severe asthma
• Mechanism of Action: stimulate beta-2 receptors in lungs
and produce smooth muscle relaxation in bronchioles
 administered less often than short-acting beta agonists
• Route: all are inhalation
• Side Effects (common): dizziness, heartburn, nausea,
tremors
• Side Effects (severe): increased BP, heart palpitations
• Caution: do not use with digoxin or beta blockers
• Caution: shake MDIs before each use
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Pneumonia and Tuberculosis (TB)
About Pneumonia
• A lower RTI caused by bacterial, viral, or fungal pathogens
• Two types of pneumonia: CAP and nosocomial
 CAP: acquired from exposure outside of an inpatient
facility
 Nosocomial pneumonia: acquired while hospitalized or
living in a long-term care facility
 Severe and difficult to treat because it is usually
caused by more virulent pathogens
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Pneumonia and Tuberculosis (TB)
About Tuberculosis
• An infectious disease caused by a mycobacterium that
infects the lungs
• It causes tubercles to form in the lungs; difficult to kill
• Incidence is on the rise due to drug-resistant strains and
more prevalent immunodeficiency conditions
• Annual PPD skin test for TB exposure required for
healthcare workers in inpatient or long-term care settings
 For PPD skin test, an injection is placed just under the
skin, then checked 48–72 hours later for inflammation
and swelling
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Pneumonia and Tuberculosis (TB)
About Tuberculosis (continued)
• For positive PPD test, chest x-ray and other tests are done
to determine if drug therapy is needed
 Not everyone exposed to TB develops the full disease
with active organisms
• Symptoms (active disease): night sweats, weight loss,
coughing blood, chest pain, fatigue
• Universal Precautions: put on gown, mask, and gloves
before entering the room of a patient with TB
 Remove these items on exiting to protect against
transmission
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Pneumonia and Tuberculosis (TB)
Drugs for Pneumonia
• A two-step treatment process is usually followed, because
determining the disease type takes time
• First process: an antibiotic covering a broad range of
pathogens is started
• Second process (narrowing treatment): lab tests and
cultures are taken to determine the bacteria or fungus
 Technicians may retrieve these results
• Once the pathogen is found, drug therapy may change
 Bronchodilators and corticosteroids may be
administered to assist labored breathing
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Pneumonia and Tuberculosis (TB)
Drugs for TB
• Drugs for TB are often specialized; not dispensed regularly
(see Table 14.6)
• Reemergence of TB due to the high rate of nonadherence
to drug therapy
 Course of therapy for TB is 6 months or longer
 Many unpleasant side effects of TB therapy
 Doses are not always taken on an empty stomach or on
a consistent basis
• Incomplete therapy promotes the emergence of drugresistant TB
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Cystic Fibrosis
About CF
• A genetic disease that affects exocrine glands and their
ability to transport chloride across cell membranes
• Thick, sticky mucus is produced in the lungs, GI system,
and pancreas; this mucus causes many problems
 Sweat glands and reproductive organs also affected
• Treatment needed for nutrition, pancreas, and respiratory
complications
• Most hospitalizations and deaths due to pulmonary
problems
 Most patients die before early to middle adulthood
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Cystic Fibrosis
Drugs for CF
• Specialized drugs; not dispensed regularly in all settings
• Respiratory therapy includes percussion (non-drug
treatment), mucolytics, and antibiotics
 Percussion is a tapping, pounding movement
performed on the back and chest
 Breaks up and helps expectorate mucus from lungs
• Nebulizer therapy with bronchodilators, hypertonic saline,
acetylcysteine accompanies use of percussion
• Antibiotics and antifungal drugs are used to combat the
bacteria and fungus in respiratory mucus secretions
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Cystic Fibrosis
Drugs for CF (continued)
• Special vitamins and pancreatic enzyme supplements are
used to help prevent ductal obstructions and steatorrhea
 Improve growth and life expectancy for children
with CF
• Pancreatic enzyme supplements all contain varying
amounts of lipase, protease, and amylase
• Fat-soluble vitamins are poorly absorbed
 Supplements containing vitamins A, D, E, and K are
often prescribed
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Smoking Cessation
About Cigarettes and Nicotine
• Cigarette smoking is the leading cause
of preventable death in the U.S.
• It contributes to heart disease, COPD, stroke, and many
malignancies in addition to lung cancer
• Nicotine in cigarettes is addictive, so smoking can be
difficult to quit
• Withdrawal from nicotine includes many symptoms
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Smoking Cessation
Symptoms of Nicotine Withdrawal
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Anxiety
Decreased blood pressure and heart rate
Depression
Drowsiness
Headache
Increased appetite and weight gain
Insomnia
Irritability, frustration, and restlessness
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Smoking Cessation
Drugs for Smoking Cessation
• Prescription and OTC medications
 Can reduce nicotine withdrawal symptoms
 Can help patients successfully quit if combined with
smoking cessation programs and social support
• Drug therapy for smoking cessation includes nicotine
supplements, antidepressants, or a nicotine blocker
• Nicotine supplements
 Available in inhaler, patch, spray, and gum forms
 Reduce absorbed nicotine slowly, which lessens
withdrawal symptoms
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Smoking Cessation
Drugs for Smoking Cessation (continued)
• Antidepressants: Bupropion
 Available in oral dosage form; prescription only
 Combats emotional instability of withdrawal
 Reduces nicotine cravings
• Nicotine Blocker: Varenicline
 Available in oral dosage form; prescription only
 Blocks nicotine from binding to pleasure receptors
 Reduces withdrawal symptoms and weight gain
 Is most effective when accompanying a formal smoking
cessation program
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Smoking Cessation
Drugs for Smoking Cessation (continued)
• Side Effects (nicotine products): abdominal pain,
confusion, diarrhea, dizziness, headache, hearing loss,
nausea, sweating, vision changes, vomiting, weakness
• Side Effects (bupropion): drowsiness, dizziness, blurred
vision, insomnia; avoid taking with alcohol
• Side Effects (varenicline): nausea, unusual dreams; take
with food and full glass of water
• Cautions (bupropion, varenicline): depression, suicidal
thoughts; boxed-in warning label alerts
• Caution (bupropion): do not stop using abruptly
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Your Turn
Question 1: A nurse is celebrating her first year of working in a
long-term care facility. How can she tell if has been exposed to
tuberculosis during that time?
Answer: She will get an annual PPD skin test. In this test, an
injection is placed just under the skin and then checked 48–
72 hours later. She will test positive if she has inflammation
and swelling at the injection site.
Question 2: What is the function of nicotine supplements that
are used for smoking cessation?
Answer: They are used to reduce absorbed nicotine slowly
over time which helps to reduce many withdrawal
symptoms.
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Herbal and Alternative Therapies
• Echinacea, zinc, and vitamin C are herbal and supplement
products that boost immune function
 Products fight off cold and flu viruses that can progress
to pneumonia
 Standardized regimens have not been proven
 Little is known about their effects on lower RTIs such as
pneumonia
• Echinacea or zinc are taken at the first sign of infection
• Vitamin C is taken as a preventive agent during cold and
flu season
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Summary
• Inhaled therapies for asthma and COPD are delivered via
MDIs, dry powder inhalers, and nebulizer machines
• Short-acting beta agonists are used for acute asthma relief
• Inhaled corticosteroids are long-term asthma treatment
• Anticholinergics are first-line, long-term COPD treatment
• Antibiotics are the initial treatment for pneumonia
• TB agents must be taken over six months
• Long-term smoking cessation success is more likely if drug
therapy is combined with cessation programs
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