DRUGS ACTING ON THE

RESPIRATORY SYSTEM

ANNGEO D. LABOG, RN, MAN

HENRY T. BARRIGA JR., RN, MN
TRACEY JOY L. DELA CRUZ, RN, MAN
MICHAEL FRANCIS T. CAHANDIG, RN, MN
 STUDENT LEARNING OUTCOME

That within my 1 - hour span of discussion, the students will be able to:

§ define antihistamine, decongestant, antitussive and expectorant;

define rhinitis, sinusitis and pharyngitis;
§ identify the side effects of nasal decongestants and explain how
they can be avoided; and
§ describe the nursing process, including client teaching, for drugs
used to treat the common upper respiratory diseases.
TOPICS
UPPER RESPIRATORY AGENTS

I. ANTIHISTAMINE
§ Diphenhydramine

II. ANTITUSSIVE
§ Dextromethorphan

III. DECONGESTANT
§ fluticasone furoate

IV. EXPECTORANT
§ guaifenesin
Common Cold
§ Caused by rhinovirus and affects primarily the
nasopharyngeal tract.

Acute Rhinitis
§ Acute inflammation of the mucus membranes of the
nose, usually accompanies the common cold.

Allergic Rhinitis
§ often called as ‘hay fever’ caused by pollen or a
foreign substance.
¡ Cold: contagious 1 – 4 days before the onset of
symptoms, and during the first 3 days of cold.
¡ Transmission: frequently from touching
contaminated surfaces then touching the nose
and mouth, viral droplets released by sneezing.
¡ Symptoms: rhinorrhea, nasal congestion, cough
and increase mucosal secretions.
¡ Bacterial: infectious rhinitis (nasal discharge
becomes tenacious, mucoid and yellow/yellow
green)
 ANTIHISTAMINES
¡ H1 blockers or H1 antagonist
¡ Compete with Histamine for receptor sites thus preventing a
histamine response
¡ Decrease nasopharyngeal secretions by blocking the H1 receptor.

¡ TWO Types (histamine receptors):

1. H1 extravascular smooth muscle including those lining

the nasal cavity are constricted.
2. H2 increase in gastric secretions occurs (cause of PUD)
 ANTIHISTAMINES
I. DIPHENHYDRAMINE

q Therapeutic Effects/ Uses:

§ To treat allergic rhinitis, itching, to prevent motion
sickness, sleep aid, antitussive
q Mode of Action:
§ Blocks Histamine1 thereby decreasing allergic
response, affects respiratory system, blood vessels
and GI system
 ANTIHISTAMINES
q PHARMACOKINETICS q PHARMACODYNAMICS
§ Absorption § PO: ONSET 15 - 45 minutes
PEAK 1 – 4 hours
§ Well absorbed
DURATION 4 – 8 hours
§ Distribution
§ PB: 98%
§ IM: ONSET 15 – 30 minutes
§ Metabolism PEAK 1 – 4 hours
§ t ½ : 2 – 7 hours DURATION 4 – 7 hours

§ Excretion
§ IV: ONSET Immediate
§ In urine as metabolites
PEAK 0.5 – 1 hour
DURATION 4 – 7 hours
 ANTIHISTAMINES
q DOSAGE
Adult:
§ PO: 25 – 50 mg q 6 – 8 hrs
§ IM/IV: 10 – 50 mg as single
dose, q 4 – 6 hrs;
MAX: 400 mg/ day
Children:
§ PO/IM/IV: 5 mg/kg/day in 4 divided
doses
MAX: 300 mg/day
 ANTIHISTAMINES

q SIDE EFFECTS q ADVERSE EFFECTS

§ dizziness, drowsiness, fatigue, § agranulocytosis, hemolytic
nausea, vomiting, urinary anemia, thrombocytopenia
retention, constipation,
blurred vision, dry mouth, and
throat, reduced secretions,
hypotension, epigastric
distress, hearing
disturbances, photosensitive
 ANTITUSSIVES
¡ Cough suppressants
¡ Act on the cough control center in the medulla to suppress the
cough reflex.
¡ Cough is a protective way to clear the airway of secretions or any
collected material.
¡ A sore throat may cause coughing that increases throat irritation.

¡ It can be taken if the cough is nonproductive and irritating.

¡ Hard candy may decrease the constant irritating cough.
 ANTITUSSIVES
I. DEXTROMETHORPHAN HYDROBROMIDE
q Therapeutic Effects/ Uses:
§ To provide temporary suppression of a
nonproductive cough; to reduce viscosity of
tenacious secretions.
q Mode of Action:
§ Inhibition of the cough center in the medulla.
 ANTITUSSIVES
q PHARMACOKINETICS q PHARMACODYNAMICS
§ Absorption § PO
§ PO: Rapidly absorbed ONSET 15 - 30 minutes
§ Distribution PEAK unknown
§ PB: unknown DURATION 3 – 6 hours
§ Metabolism
§ t½: unknown
§ Excretion
§ In urine
 ANTITUSSIVES
q DOSAGE
Adult: SUSTAINED ACTION LIQUID
§ PO: 10 – 20 mg q 4 – 8 hrs; Adult: 60 mg q 12 hrs
MAX: 120 mg/ 24 hrs Children 6- 12 yrs: 30 mg q 12 hrs
Children: 2 – 5 yrs: 15 mg q 12 hrs
§ 6- 12 years: 5 – 10 mg q 4 – 6 hrs;
MAX: 60 mg/d
§ 2 – 5 years: 2.5 – 5 mg q 4 – 8 hrs;
MAX: 30 mg/d
 ANTITUSSIVES

q SIDE EFFECTS q ADVERSE EFFECTS

§ nausea, drowsiness, dizziness, § Hallucinations at high doses
sedation
 ANTITUSSIVES

Ø (butamirate citrate)
Sinecod Forte

Ø (levodropropizine)
Levopront
 EXPECTORANTS

¡ Mucolytics, Mucokinetics, Protrussive

¡ Loosen bronchial secretions so they can be eliminated by
coughing.
¡ Found in many OTC cold remedies along with analgesics,
antihistamines, decongestants and antitussives.
¡ Hydration is the best expectorant.
 EXPECTORANTS
I. GUAIFENESIN
q Therapeutic Effects/ Uses:
§ To treat dry and unproductive cough.
§ Mobilization and subsequent expectoration
of mucus.

q Mode of Action:
§ Reduces viscosity of tenacious secretions by
increasing respiratory fluid
 EXPECTORANTS
q DOSAGE
Adult: q DRUG-LAB-FOOD INTERACTIONS
§ PO: 200 – 400 mg q 4 hrs
MAX: 2.4 g/d
§ None significant

Children:
§ 6 – 12 years: 100 – 200 mg q 4 hrs
MAX: 1.2 g/d

§ 2 – 5 years: 50 – 100 mg q 4 hrs

MAX: 600 mg/d
 EXPECTORANTS

q SIDE EFFECTS
q ADVERSE EFFECTS
§ dizziness, headache, nausea,
§ urticaria
diarrhea, stomach pain,
vomiting, rashes
 EXPECTORANTS
Ø (ambroxol HCl) Ambrolex, Mucosolvan, Ambroxol
Ø (lagundi leaf) Ascof, Ascof Forte, Lagundex
Ø (guaifenesin) Benadryl Expectorant, Robitussin
Ø (bromhexine HCl) Bisolvon, Bisolvon Forte
Ø (acetylcysteine) Exflem, Fluimucil, Nacetyl
Ø (carbocisteine) Loviscol, Solmux
 DECONGESTANTS
¡ Sympathomimetic amines, stimulate the alpha adrenergic
receptors thus producing vascular constriction of the capillaries
within the nasal mucosa.
¡ Shrinking of the nasal mucus membrane and a reduction in fluid
secretion.
¡ Nasal congestion results from dilation of nasal blood vessels
caused by infection, inflammation or allergy.
¡ There is a transudation of fluid into the tissue spaces, resulting to
swelling of the nasal cavity.
 DECONGESTANTS
Ø (diphenhydramine HCl, phenylpropanolamine HCl) Allerin Reformulated
Ø (fluticasone furoate) Avamys
 NURSING RESPONSIBILITIES
ASSESSMENT
§ Determine whether there is a history of hypertension, especially
if a decongestant is an ingredient in the cold remedy.
§ Obtain baseline VS. an elevated temperature may indicate a viral
infection caused by a cold.
§ Obtain drug history, report if drug-drug interaction is possible.
§ Assess for signs/symptoms of urinary dysfunction (retention,
dysuria and frequency).
§ Assess CBC during drug therapy; also, the cardiac and
respiratory status
NURSING RESPONSIBILITIES

DIAGNOSIS
§ Impaired tissue integrity
§ Fluid volume deficit
§ Fatigue
§ Disturbed sleeping pattern resulting from
chronic coughing
§ Risk for infection
 NURSING RESPONSIBILITIES

PLANNING
§ Client will be free of nonproductive cough. A secondary
bacterial infection does not occur.
NURSING INTERVENTIONS
§ Monitor VS. BP can become elevated when a decongestant is
taken. Dysrhythmias can also occur.
§ Observe color of bronchial secretions. Yellow or green mucus
(bronchial infection). Antibiotics may be needed.
 NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
§ Instruct the client on proper use of a nasal spray and proper use
of puff or squeeze products.
§ Advise the client to read the label on OTC drugs.
§ Inform the client that antibiotics are not helpful in treating common
cold viruses.
§ Advise elderly clients with heart disease, asthma, emphysema, DM
or hypertension to inform physician concerning the selection of
drug, including OTC drugs.
 NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
§ Advise client not to drive during initial use of a cold remedy
containing an antihistamine.
§ Increase OFI.
§ Instruct not to take a cold remedy before or at bedtime.
(Decongestant: insomnia)
§ Encourage to get adequate rest and sleep.
§ Educate the client on the mode of transmission of common cold
and flu.
 NURSING RESPONSIBILITIES
NURSING INTERVENTIONS
§ Instruct to avoid environmental pollutants, smoking, and dust.
§ Instruct to perform three effective coughs before bedtime.
§ Advise client to cough effectively; take a deep breath before
coughing and must be in upright position.
§ Keep the drug out of reach of small children. Request childproof
caps.
§ Advise to contact physician if cough persist for more than 1 week
or is accompanied with fever, chest pain and headache.
 NURSING RESPONSIBILITIES
INTERVENTIONS (Antihistamines)
§ Avoid driving a motor vehicle and performing other dangerous
activities if drowsiness occurs.
§ Avoid alcohol and other CNS depressants.
§ Instruct to notify Physician if confusion or hypotension occurs.
§ Take drug at least 30 minutes before offending event and also
before meals and at bedtime during the event (prophylaxis of
motion sickness).
 NURSING RESPONSIBILITIES
INTERVENTIONS (Antihistamines)
§ Inform breastfeeding mothers that small amounts of drug pass
into the breast milk.
§ Instruct family members that children and elderly are more
sensitive to the effects of diphenhydramine:
§ Children: nightmares, nervousness, irritability
§ Elderly: confusion, difficult or painful urination, dizziness, drowsiness, feeling
faint, dryness of the mouth, nose and throat

§ Suggest using sugarless candies or gums/ ice chips (relief for

mouth dryness)
LOWER RESPIRATORY AGENTS
 OBJECTIVES
That within my 1 - hour span of discussion, the students will be able to:
a. define Chronic Obstructive Pulmonary Disease (COPD) and
Restrictive Lung Disease;
b. list the drug groups used to treat COPD & asthma and the desired
effects of each;
c. explain the therapeutic effects of leukotriene antagonists,
glucocorticoids, antihistamines and mucolytics for asthma and
COPD; and
d. describe the nursing process, including client teaching, for drugs
used to treat the common lower respiratory diseases.
 TOPICS
LOWER RESPIRATORY AGENTS
I. SYMPATHOMIMETICS: ALPHA and BETA2
ADRENERGIC AGONIST
q isoproterenol, metaproterenol, albuterol
II. ANTICHOLINERGICS
q ipratropium bromide
III. METHYLXANTHINE (XANTHINE) DERIVATIVES
q theophylline
 TOPICS
LOWER RESPIRATORY INFECTIONS

IV. LEUKOTRIENE RECEPTOR ANTAGONISTS

q zafirlukast, zileuton, montelukast sodium
V. GLUCOCORTICOIDS
q beclomethasone, dexamethasone, hydrocortisone
 INTRODUCTION
¡ COPD: caused by airway obstruction with increased
resistance to airflow to lung tissues.
¡ 4 Major Pulmonary Disorders cause COPD;
Chronic Bronchitis
Bronchiectasis
Emphysema
Asthma
¡ Chronic Bronchitis. Bronchiectasis and Emphysema:
result in irreversible lung tissue damage.
 INTRODUCTION

¡ Restrictive Lung Disease:

- 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, and disorders
affecting the thoracic muscular wall
 SYMPATHOMIMETICS
¡ Sympathomimetics: Alpha and Beta2 Adrenergic Agonist
¡ Increases cAMP (cyclic adenosine monophosphate): dilation of
bronchioles
¡ Decrease nasopharyngeal secretions by blocking the H1 receptor.

¡ TWO Types (histamine receptors):

1. H1 extravascular smooth muscle including those lining

the nasal cavity are constricted.
2. H2 increase in gastric secretions occurs (cause of PUD)
 SYMPATHOMIMETICS
I. TERBUTALINE, FENOTEROL, SALMETEROL

q Therapeutic Effects/ Uses:

§ To treat bronchospasm, asthma; to promote
bronchodilation
q Mode of Action:
§ Relaxation of smooth muscle of bronchi
 SYMPATHOMIMETICS
q PHARMACOKINETICS q PHARMACODYNAMICS
§ Absorption § PO: ONSET 15 - 30 minutes

§ Well absorbed PEAK 1 hour

DURATION 4 hours
§ Distribution
§ PB: unknown
§ SC: ONSET 1 – 5 minutes
§ Metabolism PEAK 1 hour
§ t ½ : unknown DURATION 3 – 4 hours

§ Excretion
§ In urine as metabolites
 SYMPATHOMIMETICS
q DOSAGE
Adult:
§ PO: 25 – 50 mg q 6 – 8 hrs
§ IM/IV: 10 – 50 mg as single
dose, q 4 – 6 hrs;
MAX: 400 mg/ day

Children:
§ PO/IM/IV: 5 mg/kg/day in 4 divided
doses
MAX: 300 mg/day
 SYMPATHOMIMETICS
q SIDE EFFECTS q ADVERSE EFFECTS
§ Nervousness, tremors, § tachycardia, palpitations,
restlessness, insomnia, hypertension
headache, nausea, vomiting,
hyperglycemia, muscle
cramping of the lower
extremities
 ANTICHOLINERGICS
I. IPRATROPIUM BROMIDE

q Therapeutic Effects/ Uses:

§ Bronchodilation without systemic anticholinergic
effects.
q Mode of Action:
§ Inhibits cholinergic receptors in bronchial smooth
muscle resulting in decreased concentrations of
cyclic guanosine monophosphate (cGMP),
producing local bronchodilation.
 ANTICHOLINERGICS
q PHARMACOKINETICS q PHARMACODYNAMICS
§ Absorption § Inhalation:
§ Minimal systemic absorption ONSET 1 - 3 minutes
§ 2% (inhalation), <20% following nasal use PEAK 1 – 2 hours

§ Distribution DURATION 4 – 6 hours

§ 15% of dose reaches lower airways after

inhalation § Intranasal:
§ Metabolism ONSET 15 minutes
§ t ½ : 2 hours PEAK unknown
DURATION 6 – 12 hours
§ Excretion
§ Small amounts absorbed are metabolized by
the liver
 ANTICHOLINERGICS
q SIDE EFFECTS q ADVERSE EFFECTS
§ dizziness, headache, § palpitations, hypotension,
nervousness, blurred vision, sore allergic reactions
throat, epistaxis, nasal dryness/
irritation, bronchospasm, cough,
GI irritation, nausea, rash
 METHYLXANTHINE DERIVATIVES

¡ Second major group of bronchodilators used to treat asthma

¡ Stimulates the CNS and respiration, dilates coronary and
pulmonary vessels, causing diuresis.
¡ Used to treat asthma because of its effect on respiration and
pulmonary vessels.
¡ Includes: aminophylline, theophylline
 METHYLXANTHINE DERIVATIVES
I. THEOPHYLLINE
q Therapeutic Effects/ Uses:
§ To promote bronchodilation
§ To treat asthma and COPD
q Mode of Action:
§ Inhibits phosphodiesterase, producing increased
tissue concentration of cAMP results in
bronchodilation; diuresis cardiac, CNS and gastric
acid stimulation/secretion
 METHYLXANTHINE DERIVATIVES
q PHARMACOKINETICS q PHARMACODYNAMICS
§ Absorption § PO: ONSET 30 minutes
PEAK 1 – 2 hours
§ Well absorbed (PO)
DURATION 6 hours
§ Slowly absorbed (SR)

§ Distribution
§ SR: ONSET 1 – 3 hours
§ PB: approx. 60% PEAK 4 – 8 hours
§ Metabolism DURATION 8 – 24 hours

§ t½: 7 – 9 hours for nonsmokers

4 – 5 hours for smokers § IV: ONSET Rapid
PEAK unknown
§ Excretion
DURATION 6 – 8 hours
§ In urine
 METHYLXANTHINE DERIVATIVES
q SIDE EFFECTS q ADVERSE EFFECTS
§ anorexia, nausea, vomiting, § seizures, cardiac
restlessness, dizziness, dysrhythmia, convulsions
insomnia, flushing, rash,
headache, irritability, tremors,
tachycardia, palpitations,
urticaria
 LEUKOTRIENE RECEPTOR ANTAGONISTS

¡ Chemical mediator that can cause inflammatory changes in the

lung.
¡ Cysteinyl leukotrienes promote an increase in eosinophil
migration, mucus production, and airway wall edema; results in
bronchoconstriction.
¡ LT receptor antagonist and LT synthesis inhibitors called
leukotriene modifiers are effective in decreasing the inflammatory
symptoms of asthma triggered by allergic and environmental
stimuli.
 LEUKOTRIENE RECEPTOR ANTAGONISTS
I. MONTELUKAST SODIUM

q Therapeutic Effects/ Uses:

§ To decrease frequency and severity of acute
asthma attacks. Decreased severity of allergic rhinitis.
q Mode of Action:
§ Antagonizes the effects of leukotrienes which mediate
the following: airway edema, smooth muscle
constriction, altered cellular activity; decreasing
inflammatory process in asthma and allergic rhinitis.
 LEUKOTRIENE RECEPTOR ANTAGONISTS
q PHARMACOKINETICS q PHARMACODYNAMICS
§ Absorption § PO (swallow):

§ Rapidly absorbed (PO) 63 – 73% ONSET within 24 hours

PEAK 3 – 4 hours
§ Distribution
DURATION 24 hours
§ PB: 99 %

§ Metabolism § PO (chew):
§ t½: 2.7 – 5.5 hours
ONSET within 24 hours
§ Excretion PEAK 2 – 2.5 hours

§ Metabolize in liver, metabolites DURATION 24 hours

eliminated in feces via bile
 LEUKOTRIENE RECEPTOR ANTAGONISTS
q SIDE EFFECTS q ADVERSE EFFECTS
§ fatigue, headache, weakness, § Eosinophilic conditions, fever
otitis (children), sinusitis
(children), cough, rhinorrhea,
abdominal pain, diarrhea
(children), dyspepsia, nausea
(children), increase liver
enzymes, rash
 GLUCOCORTICOIDS
¡ Corticosteroid family
¡ Used to treat respiratory disorders, specifically asthma
¡ Have an anti-inflammatory action; indicated if unresponsive to
bronchodilator therapy or if the client has an asthma attack while
on maximum doses of theophylline or an adrenergic drug.
¡ Synergistic effect with Beta2 agonist.
¡ Can irritate mucosa, must be taken with food to avoid ulceration.
 GLUCOCORTICOIDS
I. HYDROCORTISONE

q Therapeutic Effects/ Uses:

§ Management of adrenocortical
insufficiency.
§ Costicosteroids, Antiasthmatics
q Mode of Action:
§ Suppresses inflammation and the normal immune
response.
 GLUCOCORTICOIDS
q PHARMACOKINETICS q PHARMACODYNAMICS
§ Absorption § PO: ONSET unknown

§ Well absorbed after oral administration PEAK 1 – 2 hours

DURATION 1 – 1.5 days
§ Distribution
§ IM: ONSET rapid
§ Widely distributed, crosses the
placenta and enters the breast milk. PEAK 1 hour
DURATION variable
§ Metabolism
§ t½: 1.5 – 2 hours § IV: ONSET rapid
PEAK unknown
§ Excretion
DURATION unknown
§ Metabolize in liver
 GLUCOCORTICOIDS

q SIDE EFFECTS q ADVERSE EFFECTS

§ depression, headache, § Thromboembolism, Peptic
increased ICP (children), Ulceration
restless, cataracts, increased
IOP, hypertension, anorexia,
nausea, vomiting, acne,
hirsutism, petechiae,
hyperglycemia, fluid retention,
weight gain, moon face,
buffalo hump
 NURSING RESPONSIBILITIES
ASSESSMENT
§ Assess baseline VS.
§ Obtain drug history, report if drug-drug interaction is possible.
§ Assess for wheezing, decrease breath sounds, cough and sputum
production.
§ Assess sensorium levels for confusion and restlessness caused
by hypoxia and hypercapnia.
§ Assess theophylline blood levels; toxic > 20 mcg/ml (Normal: 10 – 20 mcg/ml)

§ Assess hydration
 NURSING RESPONSIBILITIES

DIAGNOSIS
§ Ineffective airway clearance
§ Activity intolerance
§ Knowledge deficit (OTC)

PLANNING
§ Client will be free of wheezing or significantly improved.
§ Client’s lungs will be clear within 2 to 5 days.
 NURSING RESPONSIBILITIES

INTERVENTIONS
§ Monitor VS. BP may decrease & HR may increase. Check for
cardiac dysrhythmias.
§ Teach client to monitor PR.
§ Provide adequate hydration.
§ Monitor serum plasma theophylline levels
§ Administer at regular RTC to have a sustained therapeutic levels
 NURSING RESPONSIBILITIES
INTERVENTIONS
§ Administer after meals, decrease GI distress.
§ Do not crush enteric coated tablet or SR tablets/ capsules.
§ Provide pulmonary therapy (chest tapping, postural drainage)
§ Advise client not to take OTC drugs without consulting a
physician.
§ Instruct client to avoid smoking.
§ Discuss ways to alleviate anxiety; relaxation techniques & music.