CHAPTER 17 Online Video: Bronchoconstriction

UNIT 3 MEDICATIONS AFFECTING THE THERAPEUTIC USES

RESPIRATORY SYSTEM

Airflow Disorders Albuterol, levalbuterol

CHAPTER 17
ROUTE
●● Inhaled, short‑acting
●● Oral, long‑acting (albuterol)
Asthma is a chronic inflammatory disorder of the
THERAPEUTIC USES
airways. It is an intermittent and reversible ●● Prevention of asthma episode (exercise‑induced)
airflow obstruction that affects the bronchioles. ●● Inhaled, short‑acting, used for prevention of asthma
●● Treatment for bronchospasm
The obstruction occurs either by inflammation or ●● Long‑term control of asthma
airway hyper‑responsiveness leading to
Formoterol, salmeterol
bronchoconstriction.
ROUTE: Inhaled, long‑acting
Medication management usually addresses both THERAPEUTIC USES: Long‑term control of asthma
inflammation and bronchoconstriction. These
Terbutaline
same medications can also be used to treat the
ROUTE: Oral, long‑acting
manifestations of chronic obstructive pulmonary
THERAPEUTIC USES: Long‑term control of asthma
disease (COPD).

Medications include bronchodilator agents, such COMPLICATIONS

as beta2 ‑adrenergic agonists, methylxanthines,
inhaled anticholinergics, and anti‑inflammatory
agents, such as glucocorticoids, mast cell
stabilizers, and leukotriene modifiers.
Tachycardia, angina
Oral agents can cause tachycardia and angina due to
activation of alpha1 receptors in the heart.
NURSING CONSIDERATIONS
●● Advise clients to observe for chest, jaw, or arm pain or
palpitations and to notify the provider if they occur.

Beta2 ‑adrenergic agonists ●● Instruct clients to check pulse and to report an increase
of greater than 20 to 30 beats/min.
SELECT PROTOTYPE MEDICATION: Albuterol ●● Advise clients to avoid caffeine.
●● Dosage might need to be reduced.
OTHER MEDICATIONS
●● Formoterol
Tremors
●● Levalbuterol
●● Salmeterol Caused by activation of beta2 receptors in skeletal muscle
●● Terbutaline
NURSING CONSIDERATIONS
●● Tremors usually resolve with continued medication use.
Dosage might need to be reduced.
PURPOSE
●●

EXPECTED PHARMACOLOGICAL ACTION CONTRAINDICATIONS/PRECAUTIONS

Beta2‑adrenergic agonists act by selectively activating the ●● Pregnancy Risk Category C
beta2‑receptors in the bronchial smooth muscle, resulting ●● Contraindicated in clients who have tachydysrhythmia.
in bronchodilation. As a result of this: ●● Use cautiously in clients who have diabetes mellitus,
●● Bronchospasm is relieved. hyperthyroidism, heart disease, hypertension,
●● Histamine release is inhibited. and angina.
●● Ciliary motility is increased.

RN PHARMACOLOGY FOR NURSING CHAPTER 17  Airflow Disorders 125

 Online Video: Asthmatic Breathing Metered-Dose Inhaler

INTERACTIONS ●● A short‑acting beta2‑agonist is used to treat an

acute episode.
Use of beta‑adrenergic blockers can negate effects of ●● Advise clients to observe for indications of an
both medications.
impending asthma episode and to keep a log of the
NURSING CONSIDERATIONS: Beta‑adrenergic blockers
frequency and intensity of exacerbations.
should not be used concurrently. ●● Instruct clients to notify the provider if there
MAOIs and tricyclic antidepressants can increase the risk is an increase in the frequency and intensity of
of tachycardia and angina. asthma exacerbations.
NURSING CONSIDERATIONS: Instruct clients to report
changes in heart rate and chest pain.
NURSING EVALUATION OF
MEDICATION EFFECTIVENESS
NURSING ADMINISTRATION Depending on therapeutic intent, effectiveness is
●● Instruct clients to follow manufacturer’s instructions evidenced by
for use of metered‑dose inhaler (MDI), dry‑powder ●● Long‑term control of asthma

inhaler (DPI), and nebulizer. ●● Prevention of exercise‑induced asthma

●● When a client has prescriptions for an inhaled ●● Resolution of asthma exacerbations as evidenced by

beta2‑agonist and an inhaled glucocorticoid, advise absence of shortness of breath, clear breath sounds,
the client to inhale the beta2‑agonist before inhaling absence of wheezing, and return of respiratory rate
the glucocorticoid. The beta2‑agonist promotes to baseline
bronchodilation and enhances absorption of
the glucocorticoid.
●●

●●
Advise clients not to exceed prescribed dosages.
Ensure that clients know the dosage schedule
Methylxanthines
(if the medication is to be taken on a fixed or SELECT PROTOTYPE MEDICATION: Theophylline
as‑needed schedule).
●● Formoterol and salmeterol are long‑acting beta2‑agonist
inhalers. These inhalers are used every 12 hr for PURPOSE
long‑term control and are not used to abort an asthma
EXPECTED PHARMACOLOGICAL ACTION
attack, or exacerbation. These long‑acting agents are ●● Relaxation of bronchial smooth muscle, resulting
not used alone but are prescribed in combination with
in bronchodilation
an inhaled glucocorticoid. ●● Once the first‑line medication for asthma, now used
infrequently because newer medications are safer and
more effective

THERAPEUTIC USES: Oral theophylline is used for

long‑term control of chronic asthma or COPD.

ROUTE OF ADMINISTRATION: oral or IV (emergency

use only)
17.1  Metered-dose inhaler

COMPLICATIONS
Mild toxicity reaction can include
GI distress and restlessness.
More severe reactions can occur with higher therapeutic
levels and can include dysrhythmias and seizures.

NURSING CONSIDERATIONS
●● Monitor theophylline serum levels to keep within
therapeutic range (5 to 15 mcg/mL). Adverse effects are
unlikely to occur at levels less than 20 mcg/mL.
●● If manifestations occur, stop the medication. Activated
charcoal is used to decrease absorption, lidocaine is
used to treat dysrhythmias, and diazepam is used to
control seizures.
●● Instruct client that periodic monitoring of blood levels
is needed. Advise client to report nausea, diarrhea, or
restlessness, which are indicative of toxicity.

126  CHAPTER 17  Airflow Disorders CONTENT MASTERY SERIES

 CONTRAINDICATIONS/PRECAUTIONS Inhaled anticholinergics
●● Pregnancy Risk Category C SELECT PROTOTYPE MEDICATION: Ipratropium
●● Use cautiously in clients who have heart disease,
OTHER MEDICATIONS: Tiotropium
hypertension, liver and kidney dysfunction,
and diabetes mellitus.
Use cautiously in children and older adults.
PURPOSE
●●

EXPECTED PHARMACOLOGICAL ACTION: Block

INTERACTIONS muscarinic receptors of the bronchi, resulting in
bronchodilation
Caffeine
●● Caffeine increases CNS and cardiac adverse effects THERAPEUTIC USES
of theophylline. ●● Relieve bronchospasm associated with COPD
●● Caffeine can increase theophylline levels. ●● Allergen‑induced and exercise‑induced bronchospasm
●● NURSING CONSIDERATIONS: Advise clients to

ROUTE OF ADMINISTRATION: inhalation

avoid consuming caffeinated beverages (coffee,
caffeinated colas).

Phenobarbital, phenytoin, and rifampin decrease COMPLICATIONS

theophylline levels.
NURSING CONSIDERATIONS: When theophylline is used Local anticholinergic effects
concurrently with these medications, increase the dosage
Dry mouth, hoarseness
of theophylline.
NURSING CONSIDERATIONS: Advise clients to sip fluids
Cimetidine, ciprofloxacin, and other fluoroquinolone
and suck on sugar‑free hard candies to control dry mouth.
antibiotics increase theophylline levels.
NURSING CONSIDERATIONS: When theophylline is used
concurrently with these medications, decrease the dosage
of theophylline.
CONTRAINDICATIONS/PRECAUTIONS
●● Pregnancy Risk Category B
●● Contraindicated in clients who have an allergy to
NURSING ADMINISTRATION peanuts because the medication preparations can
contain soy lecithin.
●● Advise clients to take the medication as prescribed. ●● Use cautiously in clients who have narrow‑angle
If a dose is missed, the following dose should not
glaucoma and benign prostatic hyperplasia (due to
be doubled.
anticholinergic effects).
●● Instruct clients to not chew or crush sustained‑release
preparations. These medications should be
swallowed whole.
NURSING ADMINISTRATION
●● Advise clients to rinse the mouth after inhalation to
NURSING EVALUATION OF decrease unpleasant taste.
MEDICATION EFFECTIVENESS ●● Usual adult dosage is 2 puffs. Instruct clients to wait the
length of time directed between puffs.
Depending on therapeutic intent, effectiveness is ●● If two inhaled medications are prescribed, instruct
evidenced by long‑term control of asthma and COPD.
clients to wait at least 5 min between medications.
●● Advise clients not to swallow tiotropium capsules.
An inhalation device is used for administration of
the capsule.

NURSING EVALUATION OF
MEDICATION EFFECTIVENESS
Depending on therapeutic intent, effectiveness is
evidenced by the following.
●● Control of bronchospasm in clients who have COPD

●● Prevention of allergen‑induced and

exercise‑induced bronchospasm

RN PHARMACOLOGY FOR NURSING CHAPTER 17  Airflow Disorders 127

 Glucocorticoids PREDNISONE
SELECT PROTOTYPE MEDICATIONS Prednisone when used for 10 days or more can result in:
●● Inhalation: beclomethasone
●● Oral: prednisone Suppression of adrenal gland function
OTHER MEDICATIONS Such as a decrease in the ability of the adrenal cortex to
●● Inhalation produce glucocorticoids (can occur with inhaled agents
◯◯ Budesonide and oral agents)
◯◯ Budesonide and formoterol

◯◯ Fluticasone and salmeterol

NURSING CONSIDERATIONS
●● Administer oral glucocorticoid on an alternate‑day
◯◯ Fluticasone

dosing schedule.
◯◯ Mometasone and formoterol
●● Monitor blood glucose levels.
●● Oral: prednisolone ●● Taper the dose. Do not stop abruptly.
●● IV
◯◯ Hydrocortisone

◯◯ Methylprednisolone
Bone loss
Can occur with inhaled agents and oral agents

NURSING CONSIDERATIONS
PURPOSE ●● Advise clients to perform weight‑bearing exercises.
EXPECTED PHARMACOLOGICAL ACTION ●● Advise clients to consume a diet with sufficient calcium
●● Prevent inflammation, suppress airway mucus and vitamin D intake.
production, and promote responsiveness of beta 2 ●● Use the lowest dose possible to control manifestations.
receptors in the bronchial tree ●● Oral medications should be given on an alternate‑day
●● Reduction in airway mucosa edema dosing schedule.

The use of glucocorticoids does not provide

Hyperglycemia and glycosuria
immediate effects, but rather promotes
decreased frequency and severity of NURSING CONSIDERATIONS
exacerbations and acute attacks. ●● Clients who have diabetes should have their blood
glucose monitored.
THERAPEUTIC USES ●● Clients might need an increase in insulin dosage.
●● Short‑term IV agents are used for status asthmaticus.
●● Inhaled agents are used for long‑term prophylaxis
Myopathy
of asthma.
●● Short‑term oral therapy is used to treat manifestations As evidenced by muscle weakness
following an acute asthma episode.
NURSING CONSIDERATIONS
●● Long‑term oral therapy is used to treat chronic, ●● Instruct clients to report signs of muscle weakness.
severe asthma. ●● Medication dosage should be decreased.
●● Promote lung maturity and decrease respiratory distress
in fetuses at risk for preterm birth.
Peptic ulcer disease
NURSING CONSIDERATIONS
COMPLICATIONS ●● Advise clients to avoid NSAIDs.
●● Advise clients to report black, tarry stools. Check stool
for occult blood periodically.
BECLOMETHASONE ●● Administer with food or meals.

Difficulty speaking, hoarseness, and candidiasis

Infection
NURSING CONSIDERATIONS
NURSING CONSIDERATIONS: Advise clients to notify the
●● Advise clients to rinse mouth or gargle with water
provider if early manifestations of infection occur (sore
after use.
throat, weakness, malaise).
●● Advise clients to monitor for redness, sores, or white
patches and to report to provider if they occur. Treat
Disturbances of fluid and electrolytes
candidiasis with nystatin oral suspension.
Fluid retention as evidenced by weight gain, and edema
and hypokalemia as evidenced by muscle weakness

NURSING CONSIDERATIONS: Instruct clients to observe

for manifestations and report to the provider.

128  CHAPTER 17  Airflow Disorders CONTENT MASTERY SERIES

 CONTRAINDICATIONS/PRECAUTIONS NURSING EVALUATION OF
●● Pregnancy Risk Category C
MEDICATION EFFECTIVENESS
●● Contraindicated in clients who have received a live virus Depending on therapeutic intent, effectiveness is
vaccine and those who have systemic fungal infections. evidenced by the following.
●● Use cautiously in children, and in clients who have ●● Long‑term control of asthma

diabetes mellitus, hypertension, heart failure, peptic ●● Resolution of acute exacerbation as demonstrated by

ulcer disease, osteoporosis, and/or kidney dysfunction. absence of shortness of breath, clear breath sounds,
absence of wheezing, and return of respiratory rate
to baseline
INTERACTIONS
Prednisone
Leukotriene modifiers
Concurrent use of potassium‑depleting diuretics
SELECT PROTOTYPE MEDICATION: Montelukast
increases the risk of hypokalemia.
NURSING CONSIDERATIONS: Monitor potassium level and OTHER MEDICATIONS
administer supplements as needed. ●● Zileuton
●● Zafirlukast
Concurrent use of NSAIDs increases the risk of
GI ulceration.
NURSING CONSIDERATIONS: Advise clients to avoid use
of NSAIDs. If GI distress occurs, instruct clients to notify
PURPOSE
the provider. EXPECTED PHARMACOLOGICAL ACTION: Leukotriene
modifiers suppress the effects of leukotrienes, thereby
Concurrent use of glucocorticoids and hypoglycemic
reducing inflammation, bronchoconstriction, airway
agents (oral and insulin) counteract the effects.
edema, and mucus production.
NURSING CONSIDERATIONS: Clients should notify the
provider if hyperglycemia occurs. The client might need THERAPEUTIC USES: Long‑term therapy of asthma in
increased dosage of insulin or oral hypoglycemics. adults and children, and to prevent exercise‑induced
bronchospasm
●● Montelukast is used in children as young as 12 months

NURSING ADMINISTRATION of age.

●● Zafirlukast is used in children age 5 years and up.
●● Instruct clients to use glucocorticoid inhalers on ●● Zileuton is used in adolescents and adults.

a regular, fixed schedule for long‑term therapy of

asthma. Glucocorticoids are not to be used to treat an ROUTE OF ADMINISTRATION: oral
acute episode.
●● Administer using an MDI device, DPI, or nebulizer.
●● Glucocorticoid MDIs using chlorofluorocarbons (CFCs) as COMPLICATIONS
a propellant are being withdrawn from the market. The
new devices using hydroflouroalkane (HFA) no longer Depression, suicidal ideation
require a spacer to increase drug delivery.
NURSING CONSIDERATIONS: Monitor for behavior
●● When a client is prescribed an inhaled beta2‑agonist and
changes and report to provider.
an inhaled glucocorticoid, advise the client to inhale the
beta2‑agonist before inhaling the glucocorticoid. The
Liver injury with use of zileuton and zafirlukast
beta2‑agonist promotes bronchodilation and enhances
absorption of the glucocorticoid. NURSING CONSIDERATIONS
●● Oral glucocorticoids are used short‑term, 3 to 10 days ●● Obtain baseline liver function tests and
following an acute asthma exacerbation. monitor periodically.
●● If client is on long‑term oral therapy, additional dosages ●● Advise clients to monitor for indications of liver damage
of oral glucocorticoids are required in times of stress (nausea, anorexia, abdominal pain).
(infection, trauma). ●● Instruct clients to notify the provider if
●● Clients who discontinue oral glucocorticoid medications manifestations occur.
or switch from oral to inhaled agents require additional
doses of oral or IV glucocorticoids during periods
of stress. CONTRAINDICATIONS/PRECAUTIONS
●● Montelukast and zafirlukast are Pregnancy Category B.
Zileuton is Pregnancy Category C.
●● Use cautiously in clients who have liver dysfunction.

RN PHARMACOLOGY FOR NURSING CHAPTER 17  Airflow Disorders 129

 INTERACTIONS NURSING ADMINISTRATION
Zileuton and zafirlukast inhibit metabolism of warfarin ●● Advise clients to take zileuton as prescribed, 1 hr before
leading to increased warfarin levels. or after a meal.
NURSING CONSIDERATIONS ●● Advise clients to avoid taking zafirlukast with food.
●● Advise clients to observe for indications of bleeding and ●● Advise clients to take montelukast once daily at
to notify the provider. bedtime. For exercise‑induced bronchospasm, take
●● Monitor prothrombin time (PT) and INR levels. 2 hr before exercise. Instruct clients taking daily
montelukast to not take an additional dose for exercise
Zileuton and zafirlukast inhibit metabolism of
induced bronchospasm.
theophylline, leading to increased theophylline levels.
NURSING CONSIDERATIONS
Monitor theophylline levels.
NURSING EVALUATION OF
●●

●● Advise clients to observe for manifestations of

theophylline toxicity (nausea, vomiting, seizures), and
MEDICATION EFFECTIVENESS
to notify the provider. Depending on therapeutic intent, effectiveness is
evidenced by long‑term control of asthma.
Montelukast used concurrently with phenytoin can
inhibit effects of montelukast.
NURSING CONSIDERATIONS: Advise client to observe for
therapeutic effects of montelukast.

130  CHAPTER 17  Airflow Disorders CONTENT MASTERY SERIES


1. A nurse is teaching a client who has a
new prescription for beclomethasone.
Which of the following instructions
should the nurse include?
A. “Rinse your mouth after each
use of this medication.”
B. “Limit fluid intake while
taking this medication.”
C. “Increase your intake of
vitamin B12 while taking
this medication.”
D. “You can take the
medication as needed.”
Application Exercises
2. A nurse is providing instructions
to a client who has a new
prescription for albuterol and
beclomethasone inhalers for the
control of asthma. Which of the
following instructions should the
nurse include in the teaching?
A. Take the albuterol at the
same time each day.
B. Administer the albuterol
inhaler prior to using the
beclomethasone inhaler.
C. Use beclomethasone if
experiencing an acute episode.
D. Avoid shaking the
beclomethasone before use.
3. A nurse is providing instructions to
the parent of an adolescent client
who has a new prescription for
albuterol, PO. Which of the following
instructions should the nurse include?
A. “You can take this
medication to abort an
acute asthma attack.”
B. “Tremors are an adverse
effect of this medication.”
C. “Prolonged use of this
medication can cause
hyperglycemia.”
D. “This medication can slow
skeletal growth rate.”
4. A nurse is teaching a client who has
a prescription for long‑term use of
oral prednisone for treatment of
chronic asthma. The nurse should
instruct the client to monitor for
which of the following adverse
effects of this medication?
A. Weight gain
B. Nervousness
C. Bradycardia
D. Constipation

PRACTICE  Active Learning Scenario

A nurse is instructing a client who has a new
prescription for albuterol PO. What should the nurse
include in the teaching? Use the ATI Active Learning
Template: Medication to complete this item.
THERAPEUTIC USES
COMPLICATIONS: List two adverse effects.

RN PHARMACOLOGY FOR NURSING CHAPTER 17  Airflow Disorders 131

 Application Exercises Key
1. A. CORRECT: The client should rinse her mouth after each
use to reduce the risk of oral fungal infections.
B. A client who has asthma should increase fluid intake to liquefy
secretions, unless contraindicated by another condition.
C. Glucocorticoids place the client at risk for bone loss. There is no
need for the client to increase her intake of vitamin B12. The client
should ensure an adequate intake of calcium and vitamin D.
D. Beclomethasone is an inhaled glucocorticoid
and is taken on a fixed schedule.
3. A. Inhaled albuterol is used to abort an acute asthma episode.
B. CORRECT: Tremors can occur due to excessive
stimulation of beta2 receptors of skeletal muscles.
C. Prolonged use of glucocorticoids can cause hyperglycemia.
D. Glucocorticoids slow skeletal growth rate in children and adolescents.
However, height when the child reaches adulthood is not reduced.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration

NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
2. A. Albuterol is a short acting inhaled beta2‑agonist and
used for short term relief of bronchospasm.
B. CORRECT: When a client is prescribed an inhaled beta2‑agonist (such
as albuterol) and an inhaled glucocorticoid (such as beclomethasone),
the client should take the beta2‑agonist first. The beta2‑agonist promotes
bronchodilation and enhances absorption of the glucocorticoid.
C. Beclomethasone is administered on a fixed
schedule. It is not used to treat an acute attack.
D. The client should shake the metered dose
inhaler well before administration.
4. A. CORRECT: Weight gain and fluid retention are adverse effects of
oral prednisone due to the effect of sodium and water retention.
B. Nervousness and insomnia are adverse effects
of beta agonists, not glucocorticoids.
C. Tachycardia are adverse effects of prednisone and beta agonists.
D. Diarrhea is an adverse effect of prednisone.
Constipation is an adverse effect of tiotropium.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions

NCLEX® Connection: Pharmacological and Parenteral Therapies,

Medication Administration

PRACTICE Answer

Using the ATI Active Learning Template: Medication

THERAPEUTIC USES: Beta2 ‑adrenergic agonists act by

selectively activating the beta2 ‑receptors in the bronchial
smooth muscle, resulting in bronchodilation. They also
suppress histamine release and promote ciliary motility.
COMPLICATIONS
Oral agents can cause tachycardia and angina due
●●

to activation of alpha1 receptors in the heart.

Activation of beta 2 receptors in skeletal muscle causes tremors.
●●

NCLEX® Connection: Pharmacological and Parenteral

Therapies, Medication Administration

132  CHAPTER 17  Airflow Disorders CONTENT MASTERY SERIES