DRUGS ACTING ON THE RESPIRATORY SYSTEM

RESPIRATORY SYSTEM LUNG COMPLIANCE

• Divided into two parts: • The lung volume based on the unit of pressure in the alveoli.
1. Upper Respiratory System • Determines the lung's ability to stretch.
2. Lower Respiratory System • Factors that Affect Lung Compliance
• When the air enters, it starts with the Upper Respiratory 1. Connective Tissue
System the goes down into the Lower Respiratory System. o Collagen and Elastin
• The primary function of the respiratory system is to take in 2. Surface Tension in the Alveoli
oxygen and eliminate carbon dioxide. o Controlled by surfactant.
➢ The function is to move two gases: O2 and CO2 o Surfactant is the fluid that lowers surface
tension in the alveoli and prevents
UPPER RESPIRATORY SYSTEM interstitial fluid from entering.
• Consists of the following: • Increased Lung Compliance
1. Nares ➢ Present with Chronic Obstructive Pulmonary
2. Nasal Cavity Disease (COPD)
3. Pharynx • Decreased Lung Compliance
4. Larynx ➢ Occurs with Restrictive Pulmonary Disease
➢ With low compliance, there is decreased lung
LOWER RESPIRATORY SYSTEM volume resulting from increased connective tissue
• Consists of the following: or increased surface tension.
1. Trachea ➢ Lungs become stiff
2. Bronchi o Takes greater than normal pressure to
3. Bronchioles expand lung tissue.
4. Alveoli
5. Alveolar Capillary Membranes HEART
• It is where gas exchange takes place. • Considered to be as one of the major organs
• Lies on the mid-left of the chest cavity
VENTILATION • Does not connect with the lungs
• The movement of air from the atmosphere through the ➢ There is often a confusion that it is connected
Upper and Lower Airways down to the Alveoli.
• Mechanic 3 IONS THAT INFLUENCE THE CONCENTRATION
• Involves the movement of air. OF RESPIRATION
• It includes the following:
RESPIRATION 1. Oxygen
• Physiologic 2. Carbon Dioxide
• The process whereby gas exchange occurs at the Alveolar 3. Hydrogen
Capillary Membranes.
• Involves the exchange of gases in the alveoli (external CHEMORECEPTORS
respiration) and in the cells (internal respiration) • Refers to the sensors that are stimulated by changes in
• 3 Phases of Respiration these gases and ions.
1. Ventilation • Central Chemoreceptor
2. Perfusion ➢ Located in the medulla near the respiratory center
3. Diffusion and cerebrospinal fluid (CSF)
• These three phases or processes are essential for the ➢ Respond to an increase in carbon dioxide and a
transfer of oxygen from the outside air to the blood flowing decrease in pH by increasing ventilation.
through the lung. ➢ However, if the CO2 level remains elevated, the
stimulus to increase ventilation is lost.
VENTILATION • Peripheral Chemoreceptor
• Oxygen passes through the airways. ➢ Located in the carotid and aortic bodies
➢ Respond to changes in oxygen levels
• The process by which air moves in and out of the lungs.
➢ A low blood oxygen level stimulates the peripheral
chemoreceptors, which in turn stimulate the
PERFUSION
respiratory center in the medulla, and ventilation is
• Blood from the pulmonary circulation is the blood that is increased.
adequate at the Alveolar Capillary Bed. o Low Blood Oxygen Levels = < 60mmHg
• Influenced by the Alveolar Pressure ➢ If oxygen therapy increases the oxygen level in the
• The process by which the cardiovascular system pumps blood, the PO2 may be too high to stimulate the
blood throughout the lungs. peripheral chemoreceptors, and ventilation will be
• Factors that Affect Perfusion depressed.
1. Mucosal Edema o PO2 = Partial Pressure of Oxygen
2. Secretions
3. Bronchospasm
• The factors mentioned above affect the resistance of air
flow and results to decreased ventilation and diffusion of
gases.

DIFFUSION
• The molecules move from higher concentration to the lower
concentration.
• The oxygen passes into the capillary bed to be circulated
and CO2 leaves the bed and diffuses to alveoli for
ventilatory excretion.
• It is the spontaneous movement of gases, without the use
of any energy or effort by the body, between the alveoli and
the capillaries in the lungs.

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 CYCLIC ADENOSINE MONOPHOSPHATE
• Also known as the Cyclic AMP
• It is in the cytoplasm of bronchial cells
• Increases bronchodilation by relaxing the bronchial smooth
muscles
• Phosphodiesterase
➢ Pulmonary enzyme
➢ Can inactivate Cyclic AMP
• Drugs of the Methylxanthine Group (Theophylline)
➢ Inactivate phosphodiesterase
o Thus, permitting cyclic AMP to function
UPPER RESPIRATORY INFECTIONS
• Usually includes the following:
➢ Common Cold, Acute Rhinitis, Sinusitis, and Acute
Pharyngitis
• Most Common URI = Common Cold
• Adults have an average of 2 to 4 colds per year.
• Children have an average of 4 to 12 colds per year.
• Incidence is seasonally variable, with approximately 50% of
the population experiencing a winter cold and 25%
experiencing a summer cold.
• A cold is not considered a life-threatening illness, but, it
causes physical and mental discomfort and loss of time at
work and school.
• An upper respiratory infection affects the upper part of your
respiratory system, including your sinuses and throat.
COMMON COLD
• Caused by the rhinovirus
• Affects primarily the nasopharyngeal tract
• Most contagious 1 to 4 days before onset of symptoms
(incubation period) and during the first 3 days of the cold
• Symptoms:
➢ Rhinorrhea (watery nasal discharge)
➢ Nasal congestion
➢ Cough
➢ Increased mucosal secretions
• Once it becomes bacterial, secretions become yellow
➢ Due to WBC and cellular debris
➢ Antibiotics will be given already (with doctor's
order)
• Transmission occurs more frequently from touching
contaminated surfaces and then touching the nose or
mouth than it does from viral droplets released by sneezing.
ACUTE RHINITIS
• Acute inflammation of the mucous membranes of the nose
• Usually accompanies common cold
• Not the same as Allergic Rhinitis (Hay Fever)
➢ That is caused by pollens or foreign substances
• Nasal secretions increase
ANTIHISTAMINES
• Also known as H1 Blockers or H1 Antagonists
• Block the release or action of histamine
• Antihistamines are found in multiple OTC preparations that
are designed to relieve respiratory symptoms and treat
allergies.
• Histamine
➢ A chemical released during inflammation that
increase secretions and narrows airways.
• Compete with histamine for receptor sites, preventing a
histamine response.
• Two Types of Histamine Receptor
➢ H1 and H2
o Cause different responses
➢ Stimulation of H1
o Extravascular smooth muscles are
constricted
➢ Stimulation of H2
o Increase in gastric secretions
▪ Can cause peptic ulcer
• 2 Categories of Antihistamines
1. 1st Generation Antihistamines
2. 2nd Generation Antihistamines
• Not used during emergency cases
➢ Because these can be absorbed in 15 minutes
➢ Not potent enough to combat prophylaxis
• When choosing an antihistamine, the individual patient’s
reaction to the drug is usually the governing factor.
• Because first-generation antihistamines have greater
anticholinergic effects with resultant drowsiness, a person
who needs to be alert should be given one of the second-
generation, less sedating antihistamines.
• Antihistamines block the release or action of histamine, a
chemical released during inflammation that increases
secretions and narrows airways.
1ST GENERATION ANTIHISTAMINES
• Cause drowsiness, dry mouth, and other anticholinergic
symptoms.
• Diphenhydramine (Benadryl)
➢ Primary Use: Treat Rhinitis
➢ Most common 1st Generation Antihistamine
2ND GENERATION ANTIHISTAMINES
• Non-sedating Antihistamines
• Fewer anticholinergic effects and lower incidence of
drowsiness
• Still has CNS Depressant Effect
• Most Common: Cetirizine
• Cetirizine, Fexofenadine, Loratadine
➢ Half-lives between 7 and 15 hours
• Azelastine
➢ Half-life of 22 hours
ACTIONS/MOA
• Decrease nasopharyngeal secretions by blocking the H1
receptors.
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 PHARMACOKINETICS
• Diphenhydramine can be administered orally,
intramuscularly (IM), or intravenously (IV).
• It is well absorbed from the gastrointestinal (GI) tract
➢ But systemic absorption from topical use is
minimal.
• It is highly protein-bound (98%) and has an average half-
life of 2 to 7 hours.
• Diphenhydramine is metabolized by the liver and excreted
as metabolites in the urine.
PHARMACODYNAMICS
• Diphenhydramine blocks the effects of histamine by
competing for and occupying H1 receptor sites.
• It has anticholinergic effects and should not be used by
patients with narrow-angle glaucoma.
• Drowsiness is a major side effect of the drug
➢ It is sometimes used in sleep-aid products.
• Diphenhydramine is also used as an antitussive
• Its onset of action can occur in as few as 15 minutes when
taken orally and IM.
• IV administration results in an immediate onset of action.
• The duration of action is 4 to 6 hours.
• Diphenhydramine can cause CNS depression if taken with
alcohol, narcotics, hypnotics, or barbiturates.
INDICATION OF ANTIHISTAMINES
• Seasonal & perennial allergic rhinitis, allergic conjunctivitis
• Used as adjunctive therapy in anaphylactic reactions
• Nausea and vomiting associated with motion sickness
• Relief of symptoms of seasonal and perennial allergic
rhinitis, allergic conjunctivitis
• Remember: Not useful during anaphylaxis.
➢ Although histamine is involved in anaphylaxis,
treatment with antihistamines does not relieve or
prevent all of the pathophysiological symptoms of
anaphylaxis, including the more serious
complications such as airway obstruction,
hypotension, and shock.
CONTRAINDICATIONS AND CAUTIONS
• Pregnancy and lactation
• Renal or hepatic impairment
• Arrhythmias
SIDE EFFECTS
• 1st Generation Antihistamines
➢ Drowsiness, dizziness, fatigue, and disturbed
coordination
➢ Some also experiences skin rashes
➢ Anticholinergic effects
o Dry mouth
o Urine retention
o Blurred vision
INTERACTIONS
• Monoamine Inhibitor (MAOI)
➢ Diphenhydramine effect may be prolonged if taken
with MAOIs
➢ Monoamine oxidase inhibitors (MAOIs)
➢ These were the first type of antidepressant
developed.
• Ketoconazole/erythromycin
➢ May raise this drug concentration to toxic levels
NURSING CONSIDERATIONS FOR ANTIHISTAMINES
• Remember to always start with assessment.
➢ Most important step.
NURSING ASSESSMENT
• Take baseline information
➢ Temperature, BP, HR, RR, and O2 Saturation
• Be objective and particular in assessing patient
• Obtain drug history if drug interaction is probable
• Always review and double check the nurse’s notes and the
physician’s order
• Assess for signs and symptoms of urinary dysfunction
➢ Ex. Patients who have urinary retention
experiences dysuria
➢ Measure urinary output of patient
o If there’s no output, inform CI
o We can do independent nursing
interventions such as hot/cold compress
over the hypogastric area
• Assess for the cardiac and respiratory status of the patient
• History taking and examination of a patient using
antihistamines may include the following:
➢ Asses for possible contraindications/cautions
o Any history of allergy to antihistamines;
pregnancy and lactation; and prolonged
QT interval, which are contraindications
to the use of the drug; and renal or
hepatic impairment, which requires
cautious use of the drug.
➢ Perform a physical examination
o To establish baseline data for assessing
the effectiveness of the drug and the
occurrence of any adverse effects
associated with the drug therapy.
➢ Assess the skin color, texture, and lesions
o Monitor for anticholinergic effects/allergy.
➢ Evaluate orientation, affect, and reflexes
o Monitor for changes due to CNS effects.
➢ Assess respirations and adventitious sounds
o To monitor drug effects.
➢ Evaluate renal and liver function tests
o To monitor for factors that could affect
the metabolism or excretion of the drug.
NURSING IMPLEMENTATION
• Proper administration.
➢ Administer drug on an empty stomach, 1 hour
before or 2 hours after meals, to increase the
absorption.
➢ Best time to give: At Bedtime
o Due to its sleepiness/drowsiness effect
• Drug effectiveness.
➢ Note that the patient may have a poor response to
one of these agents but a very effective response
to another.
➢ The prescriber may need to try several different
agents to find the one that is most effective.
• Relief from dry mouth.
➢ Because of the drying nature of antihistamines,
patients often experience dry mouth, which may
lead to nausea and anorexia/
➢ Suggest sugarless candies or lozenges to relieve
some of the discomforts.
• Safety measures.
➢ Provide safety measures as appropriate if CNS
effects occur to prevent patient injury.
➢ If the patient is on OPD, instruct patient to take the
drug upon going home (and not prior to
driving/travelling) because of its drowsy or
sleepiness effect.
• Increase fluid intake.
➢ Increase humidity and push fluids to decrease the
problem of thickened secretions and dry nasal
mucosa.
• Ensure voiding.
➢ Have patient void before each dose to decrease
urinary retention if this is a problem.
• Skin care.
➢ Provide skin care as needed if skin dryness and
lesions become a problem to prevent skin
breakdown.
Page 3 of 9
• Avoid alcohol.
➢ Caution the patient to avoid alcohol while taking
these drugs because serious sedation can occur.
➢ This drug has a sedative effect already.
o If taken with alcohol, the sedation effect
of the drug doubles.
• Avoid OTC drugs.
➢ Caution the patient to avoid excessive dose and to
check OTC drugs for the presence of
antihistamines, which are found in many OTC
preparations and could cause toxicity.
• Health teaching.
➢ Provide thorough patient teaching, including the
drug name and prescribed dosage measure to
help avoid adverse effects, warning signs that may
indicate problems, and the need for periodic
monitoring and evaluation, to enhance patient
knowledge about the drug therapy and promote
compliance.
• Encourage patient support.
➢ Offer support and encouragement to help the
patient cope with the disease and the drug
regimen.
ANTITUSSIVES
• Suppress or inhibit coughing
• Act on the cough-control center in the medulla to suppress
the cough reflex
• Cough
➢ A naturally protective way to clear the airway of
secretions or any collected material.
• Indicated if the cough is nonproductive and irritating
➢ Nonproductive Cough
o Dry and does not produce sputum
• Major Antitussives:
➢ Benzonatate (Tessalon)
➢ Codeine
➢ Dextromethorphan Hydrobromide (Benylin)
➢ Hydrocodone Bitartrate (Hycodan)
• 3 Types of Antitussives
1. Nonnarcotic
o Non-narcotic antitussives are drugs used
for treating cold and flu symptoms.
o As this combination does not have a
narcotic drug, it helps to prevent the
adverse effects of narcotics.
o Example: Benzonatate
2. Narcotic
o Are used to treat intractable cough
(chronic cough, more than 8 weeks)
o Usually associated with lung cancer
o Examples:
▪ Codeine
▪ Hydrocodone
3. Combination Preparations
o Consist of a combination of analgesic,
antihistamine, and antitussive drugs.
o Examples:
▪ Acetaminophen,
▪ Chlorpheniramin
▪ Dextromethorphan
• Antitussives are usually used with other agents.
HARD CANDY
• May decrease the constant, irritating cough.
DEXTROMETHORPHAN
• Nonnarcotic Antitussive
• Widely used OTC Cold Remedy
• Most common antitussive
• Considered as a prototype
➢ Since it's widely used
• Example:
➢ Robitussin
➢ Benylin
• Most popular is dextromethorphan
➢ In syrup/liquid form or chewable & lozenges
• Given in numerous cold and cough remedy preparations
THERAPEUTIC ACTIONS OF ANTITUSSIVES
• Acts directly on the medullary cough center of the brain to
depress the cough reflex.
• Because they are centrally acting they are not the drugs of
choice for anyone who has a head injury or could be
impaired by the CNS depression.
INDICATION OF ANTITUSSIVES
• Local anesthetic that stimulate a cough reflex
• Treatment of dry cough
PHARMACOKINETICS
• Dextromethorphan is available in numerous cold and cough
remedy preparations in syrup or liquid form, chewable.
• Codeine, hydrocodone, and dextromethorphan are rapidly
absorbed, metabolized in the liver, and excreted in the
urine..
• They cross the placenta and enters breast milk.
• Route: Oral
• Onset: 25 to 30 minutes
• Peak: 2 hours
• Duration: 3 to 6 hours
• Metabolism: Liver
• Excretion: Urine
CONTRAINDICATIONS
• Patent Airways
➢ Patients who need to cough to maintain the
airways to avoid respiratory distress.
• Asthma and emphysema
➢ Patients with asthma and emphysema are
contraindicated because cough suppression could
lead to accumulation of secretions and a loss of
respiratory reserve.
• Addiction
➢ Patients who are hypersensitive to or have a
history of addiction to narcotics
➢ Codeine is a narcotic type; potential to addiction
• Sedation
➢ Patients who need to drive or be alert should use
codeine, hydrocodone, and dextromethorphan
with extreme caution because these drugs can
cause sedation and drowsiness.
• Pregnancy
➢ Patients who are pregnant and lactating, because
of the potential for adverse effects on the fetus or
baby, including sedation and CNS depression.
ADVERSE EFFECTS
• CNS
➢ Drowsiness and Sedation
➢ CNS Depression if used with alcohol, etc.
• GI
➢ Nausea, constipation, dry mouth, GI Upset
INTERACTIONS
• Monoamine oxidase inhibitors (MAOI)
➢ Dextromethorphan should not be used with MAOIs
because hypotension, fever, nausea, myoclonic
jerks, and coma could occur.
➢ Codeine and hydrocodone may cause excitation,
an extremely elevated temperature, hypertension
or hypotension, and coma when taken with
monoamine oxidase (MAO) inhibitors
• Alcohol, barbiturates, sedative-hypnotics, and
phenothiazines or antidepressants.
Page 4 of 9
 NURSING CONSIDERATIONS FOR ANTITUSSIVES
• The nursing considerations in administering antitussives
include the following assessment and different
implementations.
NURSING ASSESSMENT
• Taking the vital signs of the patient.
• Assess for possible contraindications and cautions
➢ E.g., history of allergy to the drug, cough for more
than 1 week, and pregnancy and lactation
• Perform a physical examination to establish baseline data.
• Monitor the temperature to evaluate for possible underlying
infection.
• Assess respirations and adventitious sounds.
• Evaluate orientation and affect.
NURSING INTERVENTIONS
• Apply the 14 Rights of Drug Administration
• Prevent overdosage.
➢ Ensure that the drug is not taken any longer than
recommended to prevent serious adverse effects
and severity respiratory tract problems.
• Assess underlying problems.
➢ Arrange for further medical evaluation for coughs
that persist or are accompanied by high fever,
rash, or excessive secretions;
➢ To detect the underlying cause of coughing, and
to arrange for appropriate treatment of the
underlying problem.
• Provide other relief measures from cough.
➢ These nursing interventions may include
humidifying the room, providing fluids, use of
lozenges, and cooling room temperature.
• Educate the patient.
➢ Provide thorough patient teaching, including the
drug name and prescribed dosage, measures to
help avoid adverse effects, warning signs that may
indicate problems, and the need for periodic
monitoring and evaluation, to enhance patient
knowledge about drug therapy and promote
compliance.
• Provide emotional support.
➢ Offer support/encouragement to help the patient
cope with the disease and the drug regimen.
ASTHMA DRUGS
LOWER RESPIRATORY TRACT DISORDER
• 2 Major Categories:
➢ COPD
➢ Restrictive Pulmonary Disease
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
• Simply known as COPD
• Caused by airway obstruction with increased airway
resistance of air flow to lung tissues.
• 4 Major Pulmonary Disorders Cause COPD
1. Chronic Bronchitis
2. Bronchiectasis
3. Emphysema
4. Asthma
• The mentioned disorders usually result in irreversible lung
tissue damage.
• The lung tissue changes resulting from an acute asthmatic
attack are normally reversible
➢ However, if the attacks are frequent and asthma
becomes chronic, irreversible changes in the lung
tissue may result.
• Patients with COPD usually have a decrease in forced
expiratory volume in 1 second (FEV1) as measured by
pulmonary function tests.
• Cigarette smoking is the most common risk factor for
COPD, especially with chronic bronchitis and emphysema.
• There is no cure for COPD at this time.
➢ However, it remains preventable in most cases.
• Because cigarette smoking is the most directly related
cause, not smoking significantly prevents COPD from
developing.
➢ Quitting smoking will slow the disease process.
ASTHMA
• An inflammatory disorder of the airway walls associated
with a varying amount of airway obstruction.
• This disorder is triggered by stimuli such as stress,
allergens, and pollutants.
• When activated by stimuli, the bronchial airways become
inflamed and edematous, leading to constriction of air
passages; bronchospasm
• Inflammation aggravates airway hyperresponsiveness to
stimuli, causing bronchial cells to produce more mucous,
which obstructs air passages.
• This obstruction contributes to wheezing, coughing,
dyspnea (breathlessness), and tightness in the chest,
particularly at night or in the early morning.
CHRONIC BRONCHITIS
• A progressive lung disease caused by smoking or chronic
lung infections.
• Bronchial inflammation and excessive mucous secretion
result in airway obstruction.
• Productive coughing is a response to excess mucus
production and chronic bronchial irritation.
• Inspiratory and expiratory rhonchi may be heard on
auscultation.
• Hypercapnia (increased carbon dioxide retention) and
hypoxemia (decreased blood oxygen) lead to respiratory
acidosis.
• Remission = Disappearance of signs and symptoms
BRONCHIECTASIS
• There is abnormal dilation of the bronchi and bronchioles
secondary to frequent infection and inflammation.
• The bronchioles become obstructed by the breakdown of
the epithelium of the bronchial mucosa.
• Tissue fibrosis may result.
EMPHYSEMA
• A progressive lung disease caused by cigarette smoking,
atmospheric contaminants, or lack of the alpha1-antitrypsin
protein that inhibits proteolytic enzymes that destroy alveoli
(air sacs).
• Proteolytic enzymes are released in the lung by bacteria or
phagocytic cells.
• The terminal bronchioles become plugged with mucus,
causing a loss in the fiber and elastin network in the alveoli.
• Alveoli enlarge as many of the alveolar walls are destroyed.
• Air becomes trapped in the overexpanded alveoli, leading
to inadequate gas (oxygen and carbon dioxide) exchange.
MEDICATIONS FREQUENTLY GIVEN TO COPD PATIENTS
• Bronchodilators
• Glucocorticoids
• Leukotriene Modifiers
• Expectorants
• Antibiotics
RESTRICTIVE LUNG DISEASE
• A decrease in total lung capacity as a result of fluid
accumulation or loss of elasticity of the lung.
• Pulmonary edema, pulmonary fibrosis, pneumonitis, lung
tumors, thoracic deformities (scoliosis), and disorders
affecting the thoracic muscular wall (e.g., myasthenia
gravis) are among the types and causes of restrictive
pulmonary disease.
Page 5 of 9
 THINGS TO REMEMBER
• Other factors that trigger asthma:
➢ Humidity, temperature changes, air pressure
changes, smoke, fumes, exhaust, perfume, stress,
emotional upset, exercise, allergies, foods, drugs
• Bronchospasm
➢ Tightening of the muscles that line the airways
(bronchi) in your lungs.
➢ When these muscles tighten, your airways narrow.
➢ Narrowed airways don't let as much air come in or
go out of your lungs.
XANTHINES
• Stimulate CNS and respiration, dilate coronary and
pulmonary vessels and cause diuresis.
• The xanthines come from a variety of naturally occurring
sources.
• These drugs were once the main treatment choices for
asthma and bronchospasm.
• However, because they have a relatively narrow margin of
safety and interact with many other drugs, they are no
longer considered the first-choice bronchodilators.
PHARMACOKINETICS
INDICATIONS
• Bronchial Asthma and COPD
• Relief of symptoms or prevention of bronchial asthma.
• Reversal of bronchospasm associated with COPD.
CONTRAINDICATIONS AND CAUTIONS
• Co-morbidities
➢ Caution should be taken with any patient with GI
problems, coronary disease, respiratory
dysfunction, renal or hepatic disease, alcoholism,
or hyperthyroidism because these conditions can
be exacerbated by the systemic effects of
xanthines.
• Long-term parenteral use
➢ Xanthines are available for oral and parenteral
use; the parenteral drug should be switched to oral
form as soon as possible because the systemic
effects of the oral form are less acute and more
manageable.
• Pregnancy
➢ Although no studies are available of xanthine
effects on human pregnancy, they have been
associated with fetal abnormalities and breathing
difficulties at birth in animal studies, so use should
be limited to situations in which the benefit to the
mother clearly outweighs the potential risk to fetus.
• Lactation
➢ Because the xanthines enter breastmilk and could
affect the baby, another method of feeding the
baby should be selected if these drugs are needed
during lactation.
CONSIDERATIONS
• To decrease side effects, don’t take with theophylline
• Serum concentration >20 mcg/ml,
➢ Toxicity occurs
➢ Can cause hyperglycemia, decreased clotting
time and rarely leukocytosis
• Avoid taking with caffeine
➢ Because of its diuretic effect
• Slow IV preps
➢ IV preparations must be administered slowly
➢ Rapid administration causes dizziness, flushing,
hypotension, severe bradycardia and palpitations
INTERACTIONS
• Nicotine
➢ Nicotine increases the metabolism of xanthines in
the liver
➢ Xanthine dose must be increased in patients who
continue to smoke while using xanthines.
ADVERSE EFFECTS
• CNS: Irritability, restlessness, dizziness.
• Cardiovascular: Palpitations, life-threatening arrhythmias.
• Others: Loss of appetite, fever, flushing.
• GU: Proteinuria.
• Respiratory: Respiratory arrest.
MEDICATIONS UNDER XANTHINE
• These are known as Methylxanthine (Xanthine)
Derivatives
• Second major group of bronchodilators used to treat
asthma is the methylxanthine (xanthine) derivatives.
• It includes:
1. Theophylline
2. Pirbuterol
3. Cromolyn Sodium
THEOPHYLLINE
• Theophylline has a low therapeutic index and a narrow
therapeutic range.
➢ Therapeutic Range: 10-20 mcg/ml
• The serum or plasma theophylline concentration level
should be monitored frequently to avoid severe adverse
effects.
• Toxicity is likely to occur when the serum level is greater
than 20 mcg/mL.
MOA
• Theophylline relaxes the smooth muscles of the bronchi,
bronchioles, and pulmonary blood vessels by inhibiting the
enzyme phosphodiesterase, resulting in an increase in
cAMP, which promotes bronchodilation.
Page 6 of 9
INDICATIONS
• Theophylline and its derivative salts are used to manage
asthma (2nd or 3rd line), chronic bronchitis and
emphysema
PIRBUTEROL
• An aerosolized bronchodilator
➢ Aerosolized
o It is dispersed or forming into a fine spray
in the air
o Given via nebulization
• May be used alone or with theophylline or steroid therapy
• Adverse Reactions:
➢ Nervousness tremors, headache, palpitations,
rapid heart rate, chest pain or tightness, nausea,
diarrhea, and dry mouth
CROMOLYN SODIUM
• Prevents the release of histamine and slow the acting
substances of anaphylaxis by stabilizing the mast cell
membrane
• Used primarily to prevent bronchial asthma
• Not useful in acute asthma attacks or status asthmaticus
• Given by inhalation to improve breathing
• Adverse Reactions:
➢ Bronchospasm, sneezing, wheezing, cough, nasal
congestion and throat irritation, dizziness, pain,
nausea, headache, and skin rash
NURSING CONSIDERATIONS FOR PATIENTS
TAKING BRONCHIDILATORS OR ANTIASTHMA
• Always start with nursing assessment then followed by
implementations or interventions.
NURSING ASSESSMENT
• History taking and physical examination of patients taking
bronchodilators or antiasthmatics.
• Always take the vital signs.
• Be objective.
• Assess for possible contraindications or caution
➢ Any known allergies to prevent hypersensitivity
reactions; cigarette use which affects the
metabolism of the drug
➢ Peptic ulcer, gastritis, renal or hepatic dysfunction,
and coronary disease, all of which could be
exacerbated and require cautious use
➢ Pregnancy and lactation, which are
contraindications because of the potential for
adverse effects on the fetus or nursing baby.
• Perform a physical examination
➢ To establish baseline data for assessing the
effectiveness of the drug and the occurrence of
any adverse effects associated with drug therapy.
• Perform a skin examination
➢ Including color and the presence of lesions
➢ To provide a baseline as a reference for drug
effectiveness.
• Monitor blood pressure, pulse, cardiac auscultation,
peripheral perfusion, and baseline electrocardiogram
➢ To provide a baseline for effects on the
cardiovascular system.
• Assess bowel sounds and do a liver evaluation and monitor
liver and renal function tests
➢ To provide a baseline for renal and hepatic
function tests.
• Evaluate serum theophylline levels
➢ To provide a baseline reference and identify
conditions that may require caution in the use of
xanthines.
• Evaluate urinary output and prostate palpation as
appropriate to monitor anticholinergic effects.
• Evaluate orientation, affect, and reflexes to evaluate CNS
effects.
NURSING IMPLEMENTATIONS/CONSIDERATIONS
• Relieve GI upset.
➢ Administer oral drug with food or milk to relieve GI
irritation if GI upset is a problem.
• Monitor drug response.
➢ Monitor patient response to the drug (e.g., relief of
respiratory difficulty, improved airflow) to
determine the effectiveness of the drug dose and
to adjust dose as needed.
• Provide comfort.
➢ Provide comfort measures including rest periods,
quiet environment, dietary control of caffeine, and
headache therapy as needed, to help the patient
cope with the effects of drug therapy.
• Provide follow-ups.
➢ Provide periodic follow-up, including blood tests,
to monitor serum theophylline levels.
• Individual drug response.
➢ Reassure patient that the drug of choice will vary
with each individual
➢ These sympathomimetics are slightly different
chemicals and are prepared in a variety of delivery
systems
➢ A patient may have to try several different
sympathomimetics before the most effective one
is found.
• Proper administration and dosage.
➢ Advise the patient to use the minimal amount
needed for the shortest period necessary to
prevent adverse effects and accumulation of drug
levels.
• Proper use of sympathomimetics.
➢ Teach the patients who use one of these drugs for
exercise-induced asthma to use it 30 to 60
minutes before exercising to ensure peak
therapeutic effects when they are needed.
• Use of adrenergic blockers.
➢ Alert the patient that long-acting adrenergic
blockers are not for use during acute attacks
because they are slower acting and will not
provide the necessary rescue in a state of acute
bronchospasm.
• Increase oral fluid intake.
➢ Ensure adequate hydration and provide
environmental controls such as the use of a
humidifier, to make the patient more comfortable.
• Encourage voiding.
➢ Encourage the patient to void before each dose of
medication to avoid urinary retention related to
drug effects.
• Small, frequent meals.
➢ Provide small, frequent meals and sugarless
lozenges to relieve dry mouth and GI upset.
• Use of inhalator.
➢ Review the use of inhalator with the patient;
caution the patient not to exceed 12 inhalations in
24 hours to prevent serious adverse effects.
• Educate the patient.
➢ Provide thorough patient teaching, including the
drug name and prescribed dosage measures to
help avoid adverse effects, warning signs that may
indicate problems, and the need for periodic
monitoring and evaluation, to enhance patient
knowledge about drug therapy and to promote
compliance.
• Provide patient support.
➢ Offer support and encouragement to help the
patient cope with the disease and the drug
regimen.
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 MUCOLYTICS AND EXPECTORANTS
EXPECTORANTS
• Drugs that liquefy the lower respiratory tract secretions.
• They are used for the symptomatic relief of respiratory
conditions characterized by a dry, nonproductive cough.
• Expectorants reduce the thickness or viscosity of bronchial
secretions thus increasing mucus flow that can be removed
more easily through coughing.
• Expectorants increase productive cough to clear the
airways.
• They liquefy lower respiratory tract secretions, reducing the
viscosity of these secretions and making it easier to cough
them up.
• Expectorants are available in many OTC preparations,
making them widely available to the patient without advice
from a health care provider.
THERAPEUTIC ACTIONS
• Enhances the output of respiratory tract fluids by reducing
the adhesiveness and surface tension of these fluids,
allowing easier movement of the less viscous secretions.
PHARMACODYNAMICS
• By increasing the production of respiratory tract fluids,
expectorants reduce the thickness, adhesiveness, and
surface tensions of mucus making it easier to clear from the
airways.
• Provide a soothing effect on the mucous membranes of the
Respiratory Tract.
• Guaifenesin is rapidly absorbed, with an onset of 30
minutes and a duration of 4 to 6 hours. guaifenesin is
absorbed through the GI tract, metabolized by the liver and
excreted primarily by the kidneys.
INDICATIONS
• For the relief of cough from minor bronchial irritation:
➢ Bronchitis, Sinusitis, Influenza, Bronchial Asthma,
and Emphysema; Other Respiratory Disorders
• Symptomatic relief of respiratory conditions characterized
by a dry, nonproductive cough.
• Underlying cough
➢ The most important consideration in the use of
these drugs is discovering the cause of the
underlying cough; prolonged use of the OTC
preparations could result in the masking of
important symptoms of a serious underlying
disorder.
ADVERSE REACTIONS
• Vomiting, Diarrhea, Drowsiness, Nausea, Abdominal Pain
➢ Vomiting can happen if it is taken in high doses of
expectorants
• GI: Nausea, vomiting, anorexia.
• CNS: Headache, dizziness.
• Respiratory: Rhinorrhea, bronchospasm.
• Skin: Rash.
DRUG INTERACTIONS
• When administered with anticoagulants, it may increase the
risk of bleeding
CONTRAINDICATIONS AND CAUTIONS
• Using acetaminophen together with warfarin is generally
considered safe.
➢ However, the risk for bleeding may increase if
higher dosages of acetaminophen (more than
1300 mg/day) are used for more than a few days
at a time, especially in individuals who are elderly,
consume alcohol regularly, or have poor nutrition.
• Allergy.
➢ This drug should not be used in patients with a
known allergy to the drug to prevent
hypersensitivity reactions.
• Pregnancy or lactation.
➢ This drug should be used with caution in
pregnancy and lactation because of the potential
adverse effects on the fetus or baby.
• Cough.
➢ This drug should not be used with persistent
coughs, which could be indicative of an underlying
medical problem.
MUCOLYTICS
• Act like detergents to liquefy and loosen thick mucous
secretions so they can be expectorated.
• Acetylcysteine (Mucomyst) is administered by nebulization.
➢ The drug should not be mixed with other drugs.
➢ When patients with asthma or hyperactive airway
disease produce increased secretions that
obstruct bronchial airways, acetylcysteine may be
administered as an adjunct to a bronchodilator
(not mixed together).
➢ The bronchodilator should be given 5 minutes
before the mucolytic.
➢ Side effects include nausea and vomiting,
stomatitis (oral ulcers), and “runny nose.”
• Work to break down mucus to aid high-risk respiratory
patients in coughing up thick, tenacious secretions.
• Mucolytics break down the chemical structure of mucus
molecules.
➢ The mucus becomes thinner and can be removed
more easily through coughing.
PHARMACOKINETICS
• Inhaled acetylcysteine is absorbed from the pulmonary
epithelium.
• When taken orally, it is absorbed from the GIT.
• Metabolized in the liver and its excretion is unknown.
• Mucolytics may be administered by nebulization or by direct
instillation into the trachea via an endotracheal tube or
tracheostomy.
PHARMACODYNAMICS
• Decreases the thickness of the respiratory tract secretions
by altering the molecular composition of mucus.
DORNASE ALFA
• An enzyme that digests the DNA in thick sputum secretions
of clients with Cystic Fibrosis (CF)
➢ Inherited disorder; causes severe damage to
lungs, digestive system & other organs in the body
➢ Cystic fibrosis affects the cells that produce
mucus, sweat and digestive juices. These
secreted fluids are normally thin and slippery.
• Helps reduce respiratory infections; improves pulmonary
functions.
Page 8 of 9
• Highly purified solution of recombinant human
deoxyribonuclease I
➢ An enzyme which selectively cleaves DNA.
• Dornase alfa hydrolyzes the DNA present in sputum/mucus
of cystic fibrosis patients and reduces viscosity in the lungs,
promoting improved clearance of secretions.
• Improvement occurs in 3 to 7 Days.
• Side effects include:
➢ Chest pain, sore throat, laryngitis, hoarseness

THERAPEUTIC ACTIONS
• Protect liver cells from being damaged during episodes of
acetaminophen toxicity because it normalizes hepatic
glutathione levels and binds with a reactive hepatotoxic
metabolite of acetaminophen.

INDICATIONS
• Liquefaction of secretions in high-risk respiratory patients
who have difficulty moving secretions including
postoperative patients
• Clearing of secretions for diagnostic tests
• Used orally to protect the liver from acetaminophen toxicity
• Treatment of atelectasis from thick mucus secretions

CONTRAINDICATIONS AND CAUTIONS

• Medical Conditions
➢ Caution should be used in cases of acute
bronchospasms, peptic ulcer, and esophageal
varices because the increased secretions could
aggravate the problem.

ADVERSE EFFECTS
• GI: Nausea, vomiting, anorexia.
• CNS: Headache, dizziness.
• Respiratory: Rhinorrhea, bronchospasm.
• Skin: Rash.

2 TYPES OF COUGH
• Productive and Nonproductive
• Productive
➢ Produces phlegm or mucus, clearing it from the
lungs.
• Nonproductive
➢ “Dry Cough”
➢ Doesn't produce phlegm or mucus.
➢ Many things — from allergies to acid reflux — can
cause a dry cough.

NURSING INTERVENTIONS (EXPECTORANTS)

• Proper administration.
• Prevent GI upset.
• Ensure safety.
• Avoid overdosage.
• Provide health education.
• Offer support.

NURSING INTERVENTIONS (MUCOLYTICS)

• Ensure drug effectiveness.
• Proper drug delivery.
• Prevent skin breakdown.
• Proper use of nebulizer.
• Proper storage.
• Provide health education.
• Provide support.

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