Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Chapter 9 Respiratory Drugs Chapter 9 Topics • • • • • Asthma Emphysema Other Lung Diseases Cough and Cold Smoking Cessation Learning Objectives • Differentiate the pulmonary diseases • Learn the pathophysiology and treatment of asthma • Define the goals of asthma treatment • Discuss the pathophysiology and treatment of emphysema and chronic bronchitis Learning Objectives • Describe other diseases related to the lungs • Be aware of the reemergence of tuberculosis and of treatment for this disease Learning Objectives • Understand how the antitussives, expectorants, decongestants, and antihistamines differ, and be able to describe their uses • Know why some drugs are prescribed for their side effects • Outline smoking cessation plans and supportive therapy Asthma • Inflammatory disease that affects the airways causing a reversible airway obstruction • Intermittent attacks are precipitated by specific triggering events • Causes a decrease in the amount of oxygen and carbon dioxide exchanged Asthma Classes • Allergic – Present in 35%-55% of patients Asthma Classes • Allergic – Present in 35%-55% of patients • Exercise Induced Asthma Classes • Allergic – Present in 35%-55% of patients • Exercise Induced • Nonallergic Upper and Lower Respiratory Tracts Exchange of Oxygen and Carbon Dioxide Asthma • Asthmatic lung is more sensitive to lower doses of allergens • Asthma has shown to have genetic predisposition Asthma Characteristics 1. Reversible small airway obstruction 2. Progressive airway inflammation 3. Increased airway responsiveness to stimuli These characteristics translate into: 1. Wheezing 2. Dyspnea 3. Acute and Chronic Cough Asthma Attack – st 1 Response • Triggered by an antigen-antibody reaction • Causes degranulation of mast cells: histamine released • Results in bronchospasm and mucus production that plugs the small airways Asthma Attack – nd 2 Response • Bronchoconstriction with delayed, sustained reactions • Causes self-sustaining inflammation Asthmatic Response Peak Flow Meter • Assesses severity of disease and aids in determining course of therapy • Measures maximum flow rate in forced expiratory maneuvers Goals of Asthma Care • • • • • Sleep well every night Be able to go to work or school every day Be free from wheezing all day Have good control of coughing Be able to continue with activities and exercise • Tolerate medicines well Asthma Therapy • Know the triggers and try to avoid them • Accurately use a Peak Flow Meter regularly • Be aware of status asthmaticus and the treatment for it. **This is a medical emergency.** Stepwise Approach to Asthma Therapy Step 1. Short-acting oral or inhaled beta-2 agonist (less than once a week); no daily medications Stepwise Approach to Asthma Therapy Step 1. Short-acting oral or inhaled beta-2 agonist (less than once a week); no daily medications Step 2. Short-acting oral or inhaled beta-2 agonist (not to exceed three to four times in one day); daily medications (e.g., inhaled corticosteroids) Stepwise Approach to Asthma Therapy Step 3. Short-acting oral or inhaled beta-2 agonist; daily medications (e.g., inhaled corticosteroid and long-acting bronchodilator) Stepwise Approach to Asthma Therapy Step 3. Short-acting oral or inhaled beta-2 agonist; daily medications (e.g., inhaled corticosteroid and long-acting bronchodilator) Step 4. Short-acting oral or inhaled beta-2 agonist; daily medications; inhaled corticosteroid, long-acting bronchodilator, long-acting beta-2 agonist, and oral corticosteroids long term Asthma Drug Therapy • • • • • Treatment should start at the most appropriate step Start with an aggressive initial approach Rescue corticosteroids may be used at any time Treatment should be reviewed every 3-6 months For exercise-induced asthma, using terbutaline or albuterol before exercise gives protection for 2 hours Devices Used in Asthma Therapy Nebulizer • Uses a stream of air that flows through liquid medication to make a fine mist to be inhaled • Very effective • Must be cleaned and taken care of to reduce risk of contamination Devices Used in Asthma Therapy • Metered Dose Inhaler (MDI) – Contains medication and compressed air – Delivers a specific amount of medication with each puff Devices Used in Asthma Therapy • Metered Dose Inhaler (MDI) – Contains medication and compressed air – Delivers a specific amount of medication with each puff • Spacer – Used with MDIs to help get medication into the lungs instead of depositing on the back of the throat Devices Used in Asthma Therapy • Dry powder inhalers – Starting to replace MDIs – The patient turns the dial and a capsule full of powder is punctured – The patient then inhales the powder Drug List Asthma Agents Bronchodilators • albuterol (Proventil, Proventil HFA, Ventolin, Ventolin HFA) • epinephrine (EpiPen) • formoterol (Foradil) • ipratropium (Atrovent) • ipratropium-albuterol (Combivent) • isoetharine (Beta-2) Drug List Asthma Agents Bronchodilators • • • • • • • isoproterenol (Isuprel) levalbuterol (Xopenex) metaproterenol (Alupent) pirbuterol (Maxair) salmeterol (Serevent) terbutaline (Brethine) tiotropium (Spiriva) albuterol (Proventil, Proventil HFA, Ventolin, Ventolin HFA) • Used in cases of airway obstruction • Relaxes bronchial smooth muscle with little effect on heart rate • HFAs do not contain chlorofluorocarbons which deplete the ozone levalbuterol (Xopenex) • • • • Isomer of albuterol Has fewer side effects than albuterol Must be used with a nebulizer Vials should be stored in foil package; once the foil is opened, vials must be used within 1 to 2 weeks salmeterol (Serevent) • • • • • Indicated for maintenance therapy Has a long duration of action Onset of action is 30-60 minutes Should not be used in rescue situations Available in MDI and dry powder inhaler ipratropium (Atrovent) • Blocks ACh in bronchial smooth muscle causing bronchodilation • Used for prevention of attacks, not rescue situations Atrovent Dispensing Issues Warning! • If patient is allergic to peanuts, they may be allergic to the suspending agent in this inhaler ipratropium-albuterol (Combivent) • Combination bronchodilator • Should inquire about peanut allergy as well Drug List Asthma Agents Xanthine Derivatives • aminophylline (Truphylline) • theophylline Drug List Asthma Agents Leukotriene Inhibitors • montelukast (Singulair) • zafirlukast (Accolate) • zileuton (Zyflo) Leukotrienes • Increase edema, mucus, and vascular permeability • 100 to 1,000 times more potent than histamine • Inhibitors block the synthesis of or the body’s response to leukotrienes montelukast (Singulair) • Indicated for the prophylaxis and chronic treatment of asthma • Do not use to treat acute attacks • Approved for use in children over 12 months • Used once a day • Available in tablet and chewable tablet Drug List Asthma Agents Corticosteroids • • • • • • beclomethasone (Beconase,Vanceril) budesonide (Pulmicort, Rhinocort) dexamethasone (Decadron) flunisolide (AeroBid) fluticasone (Flonase, Flovent) hydrocortisone (Solu-Cortef) Drug List Asthma Agents Corticosteroids • methylprednisolone (Medrol Dose-Pack, Solu-Medrol) • mometasone furoate (Nasonex) • prednisolone (Orapred, Pediapred) • prednisone (Deltasone) • triamcinolone (Azmacort, Nasacort AQ) Corticosteroids • Anti-inflammatory agent to suppress the immune response • Inhibit late-phase inflammatory reaction • Reserved for more difficult cases Corticosteroid Side Effects • Primary: – – – – Oral candidiasis Irritation and burning of the nasal mucosa Hoarseness Dry mouth Corticosteroid Side Effects • If used for a long period of time, it can cause: – – – – – Growth of facial hair in females Breast development in males Weight gain “buffalo hump” – “moon face” Easy bruising – Edema Corticosteroid Dispensing Issues Warning! • Patient should rinse mouth with water after using these inhalers to prevent oral candidiasis • Patient should be taught how to correctly use these medications fluticasone (Flonase, Flovent) • Flonase is a nasal spray used for allergies • Flovent is an MDI that comes in 3 different strengths • May take 2 weeks to reach maximum benefit budesonide (Entocort EC, Pulmicort Respules, Pulmicort Turbuhaler, Rhinocort) • Pulmicort Turbuhaler – dry powder inhaler that is breath activated and is easier to use • Coughing is a less frequent side effect mometasone furoate (Nasonex) • Decreases the amount of inflammationcausing chemicals that are released • Reverses dilation and permeability of vessels • May be used in children over 12 to prevent allergy symptoms Drug List Asthma Agents Mast Cell Stabalizers • cromolyn sodium (Crolom, Gastrocrom, Intal, Opticrom) • nedocromil (Tilade) Drug List Asthma Agents Monoclonal Antibody • omalizumab (Xolair) Drug List Asthma Agents Combination • fluticasone-salmeterol (Advair Diskus) fluticasone-salmeterol (Advair Diskus) • Combines corticosteroid (antiinflammatory) and a beta-2 agonist • Indicated for maintenance therapy in patients 12 years and older • Available in powder for inhalation Discussion Are there any problems with this order? Discussion Are there any problems with this order? Answer: Serevent should be used BID and shouldn’t receive 3 MDIs at a time… Emphysema • Characterized by destruction of air sacs • Air sacs are not able to exchange oxygen and carbon dioxide • Causes tachypnea which gives the patient a flushed look Major Risk Factors For Emphysema • • • • Cigarette smoking Occupational exposure Air pollution Genetic factors Bronchitis • Lining of the bronchial airways becomes inflamed • Acute • Chronic Bronchitis • Lining of the bronchial airways becomes inflamed • Acute – Runs a brief course • Chronic – Longer lasting condition Chronic Bronchitis • Difficult to breathe out • Characterized by cough that produces purulent, green, or blood-streaked sputum • Major Risk Factors: – Cigarette smoking, occupational hazards, fumes, environmental pollution, bacterial infection The Body’s Defense System • In a properly functioning lung: – Immune system provides good protection – Adequately removes potentially infectious agents from the lungs The Body’s Defense System • In a properly functioning lung: – Immune system provides good protection – Adequately removes potentially infectious agents from the lungs • Types of Body Defense Cells: – Ciliary carpet: rhythmically moves fluid or mucus away from the lungs The Body’s Defense System • Types of Body Defense Cells: – Goblet cells: produce mucus, increase due to smoking – Epithelial cells: produce protein-rich exudate – Type I pneumocytes: phagocytes – Type II pneumocytes: synthesize and secrete surfactant Cellular Makeup of an Alveolus and Capillary Supply Drug List COPD Agents • acetylcysteine (Acetadote, Mucomyst) – Mucolytic • dornase alfa (Pulmozyme) – Mucolytic • tiotropium (Spiriva) – Anticholinergic Other Emphysema and Bronchitis Treatments • • • • Antibiotics are sometimes needed Oxygen therapy Expectorants (Water!!!) Receive flu and pneumonia vaccinations each year Other Lung Diseases • Prevention: – – – – – Do not smoke Avoid second-hand smoke Avoid air pollution Get vaccinated WASH HANDS Pneumonia • • Common lung disease that affects all ages 3 ways to become infected: 1. Inhalation of aerosolized particles 2. Entrance through the bloodstream 3. Aspiration • Aspiration commonly occurs during sleep X-Ray of Pneumonic Lung X-Rays can be performed to check for pneumonia or to see the progression of the disease. Discussion Why is cigarette smoke implicated in many diseases that affect the lung? Discussion Why is cigarette smoke implicated in many diseases that affect the lung? Answer: Destroys the walls of the lungs, including the protective mechanisms Cystic Fibrosis • Hereditary disease that affects the gastrointestinal and respiratory systems • This is a fatal disease; death is associated with the pulmonary system • Patients have an increase in production and viscosity of mucus as well as decreased pancreatic enzymes needed for digestion Cystic Fibrosis Therapy • • • • Percussion Nebulizer therapy Antibiotic therapy Strict diets Respiratory Distress Syndrome (RDS) • Occurs in newborns during the first few hours of life • Acute asphyxia with hypoxia and acidosis inhibit the production of surfactant Respiratory Distress Syndrome (RDS) • Occurs in newborns during the first few hours of life • Acute asphyxia with hypoxia and acidosis inhibit the production of surfactant • 2 Causes: – Prematurity – Maternal diabetes Drug List Surfactants for RDS • • • • beractant (Survanta) calfactant (Infasurf) colfosceril palimate (Exosurf Neonatal) poractant alfa (Curosurf) beractant (Survanta) • Drug of choice for RDS • Extracted from cattle lung • Lowers surface tension between the alveoli to keep them from collapsing beractant (Survanta) • Prophylactic therapy: for high risk infants • Rescue therapy: to be used within 8 hours of birth Tuberculosis • Caused by mycobacterium tuberculosis • Primarily affects the lungs, but may also affect the bone and kidney tissue • Transmission: through inhaled droplets from an infected person (droplets descend 1-2 inches per hour) Tuberculosis • Seen primarily in: – – – – Alcoholics Prison population Immunocompromised Elderly 2 Classes of Tuberculosis 1. Exposed, but no disease • Test positive on TB test, but show no signs of active disease 2 Classes of Tuberculosis 1. Exposed, but no disease • Test positive on TB test, but show no signs of active disease 2. Exposed and have active organisms • Signs and symptoms are present: weight loss, spitting blood, night sweats, night fever, chest pain, malaise TB Test • A protein derivative from killed bacteria is injected intradermally • If the patient has been exposed to this organism, the test will be positive • If positive, the patient must have x-rays taken to look for signs of active disease Goals of TB Therapy 1. 2. 3. 4. Initiate treatment promptly Convert sputum culture to negative ASAP Achieve cure without relapse Prevent emergence of drug-resistant strains Drug List Tuberculosis Agents • • • • • • capreomycin (Capastat) ciprofloxacin (Cipro) cycloserine (Seromycin) ethambutol (Myambutol) ethionamide (Trecator-SC) isoniazid(INH) (Laniazid, Nydrazid) Drug List Tuberculosis Agents • • • • • • • isoniazid-pyrazinamide-rifampin (Rifater) isoniazid-rifampin (Rifamate) ofloxacin (Floxin) pyrazinamide rifampin (Rifadin, Rimactane) rifapentine (Priftin) streptomycin Treatment Regimens • Patients with no symptoms, but a positive x-ray: – INH 300 mg QD X 12 months Treatment Regimens • Patients with no symptoms, but a positive x-ray: – INH 300 mg QD X 12 months • Patients with clinical disease: – At least 2 agents at a time to prevent drugresistance Multidrug Resistant Tuberculosis • New strain has developed that is resistant to several drugs • Risk factors for acquiring MDR-TB: – – – – – Being exposed to MDR-TB Not completing TB therapy Being prescribed the inappropriate agents Having immune deficiencies Having recurrence of TB rifampin Side Effects • Causes a reddish-orange discoloration of: – Urine – Tears, sweat – Other body fluids • Can permanently stain soft contact lenses Discussion Why is patient compliance such an issue with tuberculosis patients? Discussion Why is patient compliance such an issue with tuberculosis patients? Answer: Length of therapy, side effects, inherent in some patient groups Histoplasmosis • Fungal pulmonary disease • Caused by breathing in spores from droppings of chickens, pigeons, starlings and other birds and bats • Called the summer flu because of the flulike symptoms • Amphotericin B and itraconazole are used for treatment Cough and Cold • Common colds are the most prevalent respiratory tract infections • Symptoms: – – – – – Mild malaise Runny nose Sneezing Scratchy throat Fever Colds • Bacterial sinusitis and otitis media are frequent complications warranting antibiotic therapy • OTC remedies are often used for symptom relief • Technicians should be knowledgeable about OTC preparations and be able to explain proper uses and side effects Antitussives • • Coughing clears the airways of excess secretions and foreign materials Antitussives can be useful for dry, nonproductive coughs by causing: 1. CNS depression of the cough center (reflex) 2. Suppression of the nerve receptors in the respiratory tract Cough Reflex • • Stimulated by stretch receptors and irritant receptors Follows a series of 6 events: 1. Inspiration interrupts regular breathing rhythm 2. Thorax and abdominal muscles contract rapidly 3. Airway closes Cough Reflex 4. Peristaltic muscular wave moves over the bronchi and bronchioles 5. Pressure forces the glottis open and the laryngeal muscles relax 6. Air flows outward, carrying mucus and foreign bodies Drug List Antitussives • • • • • • benzonatate (Tessalon) codeine dextromethorphan (Delsym) diphenhydramine (Benadryl) hydrocodone-homatropine (Hycodan) promethazine-codeine Drug List Antitussives Dextromethorphan Combos • dextromethorphan-pseudoephedrinebrompheniramine (Bromfed-DM, Myphetane DX) • guaifenesin-dextromethorphan (Mucinex DM) • promethazine-dextromethorphan codeine • Considered the “Gold Standard” • Has a drying effect on respiratory mucosa – Dangerous for patients with asthma or emphysema • Can be purchased without a prescription in some states; dispensing must be done by the pharmacist Codeine Side Effects • • • • Nausea Drowsiness Light-headedness Constipation benzonatate (Tessalon) • Has local anesthetic effects • Numbs the stretch receptors in the airway, lungs, and pleura • Very dangerous if chewed dextromethorphan (Delsym) • Works as well as codeine without analgesic properties • Does not depress respiration or have abuse potential • Often combined with other cough and cold preparations Expectorants • Help rid the lungs and airway of mucus when coughing • Decrease thickness and stickiness of mucus, decrease viscosity and increase expectoration of mucus • Used for dry and productive coughs Water • Can work as well as, if not better than, medication expectorants • Staying well-hydrated thins mucus and allows for easier expectoration Drug List Expectorants • • • • guaifenesin (Mucinex) potassium iodide (Iossat, Lugol solution) guaifenesin-codeine (Robitussin A-C) guaifenesin-pseudoephedrine (Mucinex D) guaifenesin • Loosens phlegm and thins bronchial secretions • Available in capsule, tablet, sustainedrelease, and liquid forms • Frequently combined with other cough and cold preparations • Okay for patients with asthma or emphysema Decongestants • Swelling and stuffiness are caused by vasodilation and leakage of fluids into the nasal mucosa • Decongestants cause constriction which promotes drainage, improves nasal ventilation, and relieves stuffiness, which then allows the sinus cavities to drain Decongestants • Length of therapy should not exceed 3-5 days • Topical decongestants may cause rebound rhinitis medicamentosa • Available in topical and oral forms Decongestant Dispensing Issues Warning! • Should be avoided in patients with: – Diabetes – Heart disease – Uncontrolled hypertension – Hyperthyroidism – Prostatic hypertrophy – Tourette’s syndrome Drug List Decongestants • pseudoephedrine (Sudafed) Combinations: • APAP-clemastine-pseudoephedrine (Tavist Allergy/Sinus/Headache) • brompheniramine-pseudoephedrine (Efidac 24) Drug List Decongestants Pseudoephedrine Combos • cetirizine-pseudoephedrine (Zytrec-D) • dexbrompheniramine-pseudoephedrine (Drixoral) • fexofenadine-pseudoephedrine (Allegra-D) • ibuprofen-pseudoephedrine (Advil Cold and Sinus, Sine-Aid IB) Drug List Decongestants Pseudoephedrine Combos • loratadine-pseudoephedrine (Claritin D) • naproxen-pseudoephedrine (Aleve Cold and Sinus) Decongestant Side Effects • Oral: – – – – – – – – – Anxiety CNS stimulation Dizziness Hallucinations Headache Increased BP Increased heart rate Insomnia Tremor • Topical: – – – – Burning sensation Contact dermatitis Dry mouth Rhinitis medicamentosa – Sneezing – Stinging sensation pseudoephedrine (Sudafed) • Most-used decongestant; available in many combinations • Current evidence shows that if hypertension is well controlled, these patients may be able to take decongestants • Will very likely become a prescription drug due to abuse potential Antihistamines • Histamine is found throughout the body • Causes increased gastric secretions, increased heart rate, and mediates hypersensitivity • 2 Types of histamine receptors: – H1 – located in upper respiratory system – H2 – located in gastrointestinal tract Antihistamines • Well absorbed and widely distributed in tissues • Crosses the blood-brain barrier – Causes sedation • Crosses the placenta – Adversely affects fetus Drug List Antihistamines (H1) • • • • • • azatadine (Optimine) azelastine (Astelin, Optivar) cetirizine (Zyrtec) clemastine (Tavist Allergy) cyproheptadine desloratadine (Clarinex) Drug List Antihistamines (H1) • • • • • • diphenhydramine (Benadryl) fexofenadine (Allegra) hydroxyzine (Atarax, Vistaril) loratadine (Claritin) meclizine (Antivert) promethazine (Phenergan) Drug List Antihistamine (H1) Combinations • brompheniramine-dextromethorphanpseudoephedrine (Bromfed-DM) • chlorpheniramine-pseudoephedrine (ChlorTrimeton) • hydrocodone-chlorpheniramine (Tussionex) • triprolidine-pseudoephedrine Therapeutic Uses • Allergies • Insomnia • Rash, edema, and hay fever • Cough • Vertigo • Nausea and vomiting • Serum sickness • Control venom reactions • Lessens extrapyramidal side effects of antipsychotics • Prevent certain drug reactions and allergies • Hypersensitivity Hypersensitivity Reactions • Excessive immune response to a foreign agent • Can range from a rash to a deadly reaction Antihistamine Side Effects • Anticholinergic responses – – – – – Dry mouth Drying of the URT mucosa Blurred vision Constipation Urinary retention • Hyperactivity in some children • Sedation is the most common Smoking Cessation • On average, cigarette smokers lose about 15 years of life • The smoke contains 4,000 chemical compounds with at least 43 carcinogens • Secondhand smoke contains all 43 carcinogens Smoking • Can lead to: – Leukemia – Cancers of the mouth, pharynx, larynx, esophagus, pancreas, cervix, kidney, bladder, ovaries, uterus, and prostate • Increases risk of: – Heart disease – COPD – Stroke Smoking • Is related to birth defects of smoking mothers • Secondhand smoke puts children at risk of developing asthma • Nicotine can react with certain medications Nicotine Effects • CNS and PNS stimulation and depression • Respiratory stimulation • Skeletal muscle relaxation • Increase in BP • Increase in heart rate • Increase in cardiac output • Increase in oxygen consumption • Physical and psychological dependence Personal Benefits to Smoking Cessation • Improved performance in sports and sex • Better-smelling home, car, clothing, and breath • Economic savings • Freedom from addiction • Healthier babies • Improved health • Improved self-esteem • Improved sense of taste and smell • No concern about exposing others to smoke • Setting a good example 5 Step Quit Plan 1. Set a date 5 Step Quit Plan 1. Set a date 2. Inform family, friends and coworkers 5 Step Quit Plan 1. Set a date 2. Inform family, friends and coworkers 3. Remove cigarettes from daily life 5 Step Quit Plan 1. 2. 3. 4. Set a date Inform family, friends and coworkers Remove cigarettes from daily life Review previous attempts and analyze what caused relapse 5 Step Quit Plan 1. 2. 3. 4. Set a date Inform family, friends and coworkers Remove cigarettes from daily life Review previous attempts and analyze what caused relapse 5. Anticipate challenges Smoking Cessation • Abstinence is the key • Some fears that keep people from quitting: – Weight gain – Nicotine withdrawal Symptoms of Nicotine Withdrawal • Anxiety • Craving tobacco • Decreased blood pressure and heart rate • Depression • Difficulty in concentrating • Drowsiness • Frustration, irritability • Gastrointestinal disturbances • Headache • Hostility • Increased appetite • Increased skin temp • Insomnia Drug List Smoking Cessation Agents • bupropion (Wellbutrin SR, Zyban) • nicotine (Commit, Habitrol, Nicoderm CQ, Nicorette, ProStep, Nicotrol) Smoking Cessation Agent Dispensing Issues Warning! • Smoking while on nicotine replacement therapy could cause signs of nicotine excess Symptoms of Nicotine Excess • • • • • • Abdominal pain Confusion Diarrhea Dizziness Headache Hearing loss • • • • • • Hypersalivation Nausea Perspiration Visual disturbances Vomiting Weakness Smoking Cessation Agent Dispensing Issues Warning! • Lozenges should not be chewed • Patch application site should be rotated to prevent skin reactions Discussion You are trying to get a friend to stop smoking. Name 5 reasons he/she should quit.