Chapter 037

Chapter 37
Respiratory Drugs
Copyright © 2017, Elsevier Inc. All rights reserved.

Diseases of the Lower Respiratory
Tract
 Chronic obstructive pulmonary disease (COPD)
 Asthma (persistent and present most of the time
despite treatment)
 Emphysema
 Chronic bronchitis
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Bronchial Asthma
 Recurrent and reversible shortness of breath

 Occurs when the airways of the lungs become
narrow as a result of:
 Bronchospasms
 Inflammation of the bronchial mucosa
 Edema of the bronchial mucosa
 Production of viscous mucus

Bronchial Asthma (Cont.)
 The alveolar ducts and alveoli remain open, but

airflow to them is obstructed.
 Symptoms
 Wheezing
 Difficulty breathing

Asthma
 Four categories
 Intrinsic (occurring in patients with no history of
allergies)
 Extrinsic (occurring in patients exposed to a known
allergen)
 Exercise induced
 Drug induced

Asthma (Cont.)
 Status asthmaticus
 Prolonged asthma attack that does not respond to
typical drug therapy
 May last several minutes to hours
 Medical emergency

Chronic Bronchitis
 Continuous inflammation and low-grade

infection of the bronchi
 Excessive secretion of mucus and certain
pathologic changes in the bronchial structure
 Often occurs as a result of prolonged exposure
to bronchial irritants

Emphysema
 Air spaces enlarge as a result of the destruction

of alveolar walls.
 Caused by the effect of proteolytic enzymes
released from leukocytes in response to alveolar
inflammation
 The surface area where gas exchange takes
place is reduced.
 Effective respiration is impaired.

Pharmacologic Overview
 Bronchodilators
 These drugs relax bronchial smooth muscle, which
causes dilation of the bronchi and bronchioles that
are narrowed as a result of the disease process.
 Three classes: beta-adrenergic agonists,
anticholinergics, and xanthine derivatives

Bronchodilators: Beta-Adrenergic
Agonists
 Short-acting beta agonist (SABA) inhalers
 albuterol (Ventolin)
 levalbuterol (Xopenex)
 pirbuterol (Maxair)
 terbutaline (Brethine)
 metaproterenol (Alupent)
 Long-acting beta agonist (LABA) inhalers
 arformoterol (Brovana)
 formoterol (Foradil, Perforomist)
 salmeterol (Serevent)
Agonists: Newest LABA
 LABA inhalers (Cont.)
 indacterol (Arcapta Neohaler)
 vilanterol in conjunction with fluticasone (Breo Ellipta)
 vilanterol in conjunction with the anticholinergic,
umeclidinium (Anoro Ellipta)
 The term Ellipta refers to a new delivery system.

Agonists (Cont.)
 Used during acute phase of asthmatic attacks
 Quickly reduce airway constriction and restore
normal airflow
 Agonists, or stimulators, of the adrenergic
receptors in the sympathetic nervous system
 Sympathomimetics

Agonists (Cont.)
 Three types
 Nonselective adrenergics
• Stimulate alpha, beta1 (cardiac), and beta2 (respiratory)
receptors
• Example: epinephrine (EpiPen)
 Nonselective beta-adrenergics
• Stimulate both beta1 and beta2 receptors
• Example: metaproterenol

Agonists (Cont.)
 Three types (Cont.)
 Selective beta2 drugs
• Stimulate only beta2 receptors
• Example: albuterol

Beta-Adrenergic Agonists:
Mechanism of Action
 Begins at the specific receptor stimulated
 Ends with dilation of the airways
 Activation of beta2 receptors activates cyclic
adenosine monophosphate (cAMP), which relaxes
smooth muscle in the airway and results in bronchial
dilation and increased airflow.

Beta-Adrenergic Agonists: Indications
 Relief of bronchospasm related to asthma,

bronchitis, and other pulmonary diseases
 Used in treatment and prevention of acute
attacks
 Used in hypotension and shock

Contraindications
 Known drug allergy
 Uncontrolled hypertension
 Cardiac dysrhythmias
 High risk of stroke (because of the
vasoconstrictive drug action)

Adverse Effects
 Alpha and beta (epinephrine)
 Insomnia
 Restlessness
 Anorexia
 Vascular headache
 Hyperglycemia
 Tremor
 Cardiac stimulation

Adverse Effects (Cont.)
 Beta1 and beta2 (metaproterenol)
 Cardiac stimulation
 Tremor
 Anginal pain
 Hypotension

Adverse Effects (Cont.)
 Beta2 (albuterol)
 Hypotension or hypertension
 Tremor

Beta-Adrenergic Agonists: Interactions
 Diminished bronchodilation when nonselective

beta blockers are used with the beta agonist
bronchodilators
 Monoamine oxidase inhibitors
 Sympathomimetics
 Monitor patients with diabetes; an increase in
blood glucose levels can occur.

Albuterol (Proventil)
 Short-acting beta2-specific bronchodilating beta
agonist
 Most commonly used drug in this class
 Must not be used too frequently
 Oral and inhalational use
 Inhalational dosage forms include metered-dose
inhalers (MDIs) as well as solutions for
inhalation.

Salmeterol (Serevent)
 Long-acting beta2 agonist bronchodilator
 Never to be used for acute treatment
 Used for the maintenance treatment of asthma
and COPD and is used in conjunction with an
inhaled corticosteroid
 Salmeterol should never be given more than
twice daily nor should the maximum daily dose
(one puff twice daily) be exceeded.

Anticholinergics:
Mechanism of Action
 Acetylcholine (ACh) causes bronchial
constriction and narrowing of the airways.
 Anticholinergics bind to the ACh receptors,
preventing ACh from binding.
 Result: bronchoconstriction is prevented,
airways dilate

Anticholinergics (Cont.)
 Ipratropium (Atrovent), tiotropium (Spiriva), and

aclidinium (Tudorza)
 Indirectly cause airway relaxation and dilation
 Help reduce secretions in COPD patients
 Indications: prevention of the bronchospasm
associated with chronic bronchitis or
emphysema; not for the management of acute
symptoms

Anticholinergics: Adverse Effects
 Dry mouth or throat

 Nasal congestion
 Heart palpitations
 Gastrointestinal (GI) distress
 Headache
 Coughing
 Anxiety

Anticholinergics: Ipratropium (Atrovent)
 Oldest and most commonly used anticholinergic

bronchodilator
 Available both as a liquid aerosol for inhalation
and as a multidose inhaler
 Usually dosed twice daily

Xanthine Derivatives
 Plant alkaloids: caffeine, theobromine, and

theophylline
 Only theophylline is used as a bronchodilator
 Synthetic xanthines: aminophylline and
dyphilline

Xanthine Derivatives:
Mechanism of Action
 Increase levels of energy-producing cAMP
 This is done by competitively inhibiting
phosphodiesterase, the enzyme that breaks down
cAMP.
 Result: decreased cAMP levels, smooth muscle
relaxation, bronchodilation, and increased
airflow

Drug Effects
 Cause bronchodilation by relaxing smooth
muscle in the airways
 Result: relief of bronchospasm and greater
airflow into and out of the lungs
 Also cause central nervous system (CNS)
stimulation

Drug Effects (Cont.)
 Also cause cardiovascular stimulation: increased
force of contraction and increased heart rate,
resulting in increased cardiac output and
increased blood flow to the kidneys (diuretic
effect)

Indications
 Dilation of airways in asthmas, chronic
bronchitis, and emphysema
 Mild to moderate cases of acute asthma
 NOT for management of acute asthma attack
 Adjunct drug in the management of COPD
 Not used as frequently because of potential for
drug interactions and variables related to drug
levels in the blood

Adverse Effects
 Nausea, vomiting, anorexia
 Gastroesophageal reflux during sleep
 Sinus tachycardia, extrasystole, palpitations,
ventricular dysrhythmias
 Transient increased urination
 Hyperglycemia

Caffeine
 Used without prescription as a CNS stimulant or
analeptic to promote alertness (e.g., for long-
duration driving or studying)
 Cardiac stimulant in infants with bradycardia
 Enhancement of respiratory drive in infants

Theophylline
 Most commonly used xanthine derivative
 Oral, rectal, injectable (as aminophylline), and topical
dosage forms
 Aminophylline: intravenous (IV) treatment of patients
with status asthmaticus who have not responded to fast-
acting beta agonists such as epinephrine
 Therapeutic range for theophylline blood level is 10 to 20
mcg/mL
 Most clinicians now advise levels between 5 and 15
mcg/mL.

Nonbronchodilating Respiratory Drugs
 Leukotriene receptor antagonists (montelukast,

zafirlukast, and zileuton)
 Corticosteroids (beclomethasone, budesonide,
dexamethasone, flunisolide, fluticasone,
ciclesonide, and triamcinolone)
 Mast cell stabilizers: rarely used cromolyn and
nedocromil, which are sometimes used for
exercise-induced asthma

Leukotriene Receptor Antagonists
(LTRAs)
 Nonbronchodilating
 Newer class of asthma medications
 Currently available drugs
 montelukast (Singulair)
 zafirlukast (Accolate)
 zileuton (Zyflo)

LTRAs:
Mechanism of Action
 Leukotrienes are substances released when a
trigger, such as cat hair or dust, starts a series of
chemical reactions in the body.
 Leukotrienes cause inflammation,
bronchoconstriction, and mucus production.
 Result: coughing, wheezing, shortness
of breath

LTRAs:
Mechanism of Action (Cont.)
 LTRAs prevent leukotrienes from attaching to
receptors on cells in the lungs and in circulation.
 Inflammation in the lungs is blocked, and asthma
symptoms are relieved.

LTRAs:
Drug Effects
 By blocking leukotrienes:
 Prevent smooth muscle contraction of the
bronchial airways
 Decrease mucus secretion
 Prevent vascular permeability
 Decrease neutrophil and leukocyte infiltration
to the lungs, preventing inflammation

LTRAs: Indications
 Prophylaxis and long-term treatment and

prevention of asthma in adults and children 12
years of age and older
 NOT meant for management of acute asthmatic
attacks
 Montelukast is also approved for treatment of
allergic rhinitis
 Improvement with their use is typically seen in
about 1 week

LTRAs: Contraindications
 Known drug allergy

 Previous adverse drug reaction
 Allergy to povidone, lactose, titanium dioxide, or
cellulose derivatives is also important to note
because these are inactive ingredients in these
drugs

LTRAs: Adverse Effects
 zileuton
 Headache, nausea, dizziness, insomnia
 zafirlukast and montelukast
 Headache, nausea, diarrhea

Corticosteroids (Glucocorticoids)
 Antiinflammatory properties
 Used for chronic asthma
 Do not relieve symptoms of acute asthma
attacks
 May be administered IV
 Oral or inhaled forms
 Inhaled forms reduce systemic effects
 May take several weeks before full
effects are seen

Corticosteroids:
Mechanism of Action
 Stabilize membranes of cells that release
harmful bronchoconstricting substances
 These cells are called leukocytes, or white
blood cells.
 Increase responsiveness of bronchial smooth
muscle to beta-adrenergic stimulation
 Dual effect of both reducing inflammation and
enhancing the activity of beta agonists

Corticosteroids:
Mechanism of Action (Cont.)
 Corticosteroids have also been shown to restore
or increase the responsiveness of bronchial
smooth muscle to beta-adrenergic receptor
stimulation, which results in more pronounced
stimulation of the beta2 receptors by beta
agonist drugs such as albuterol.

Inhaled Corticosteroids
 beclomethasone dipropionate (Beclovent)

 budesonide (Pulmicort Turbuhaler)
 dexamethasone sodium phosphate (Decadron
Phosphate Respihaler)
 flunisolide (AeroBid)
 fluticasone (Flovent)
 triamcinolone acetonide (Azmacort)
 ciclesonide (Omnaris)

Inhaled Corticosteroids: Indications
 Primary treatment of bronchospastic disorders to

control the inflammatory responses that are
believed to be the cause of these disorders
 Persistent asthma
 Often used concurrently with the beta-
adrenergic agonists
 Systemic corticosteroids are generally used only
to treat acute exacerbations, or severe asthma
 IV corticosteroids: acute exacerbation of asthma
or other COPD
Inhaled Corticosteroids:
Contraindications
 Drug allergy
 Not intended as sole therapy for acute asthma
attacks
 Hypersensitivity to glucocorticoids
 Patients whose sputum tests positive for
Candida organisms
 Patients with systemic fungal infection

Adverse Effects
 Pharyngeal irritation
 Coughing
 Dry mouth
 Oral fungal infections
 Systemic effects are rare because low doses are
used for inhalation therapy.

Drug Interactions
 Drug interactions are more likely to occur with
systemic (versus inhaled) corticosteroids.
 May increase serum glucose levels, possibly
requiring adjustments in dosages of antidiabetic
drugs
 Cyclosporine and tacrolimus
 Itraconazole
 Phenytoin, phenobarbital, and rifampin

Phosphodiesterase-4 Inhibitor
 roflumilast (Daliresp)
 Indicated to prevent coughing and excess mucus
from worsening and to decrease the frequency of life-
threatening COPD exacerbations
 Adverse effects include nausea, diarrhea, headache,
insomnia, dizziness, weight loss, and psychiatric
symptoms.

Monoclonal Antibody Antiasthmatic
 omalizumab (Xolair)
 Selectively binds to the immunoglobulin E, which in
turn limits the release of mediators of the allergic
response
 Omalizumab is given by injection
 Potential for producing anaphylaxis
 Monitor closely for hypersensitivity reactions.

Nursing Implications
 Encourage patients to take measures that

promote a generally good state of health so as
to prevent, relieve, or decrease symptoms of
COPD.
 Avoid exposure to conditions that precipitate
bronchospasm (allergens, smoking, stress, air
pollutants).
 Adequate fluid intake
 Compliance with medical treatment
 Avoid excessive fatigue, heat, extremes in
temperature, and caffeine.
Nursing Implications (Cont.)
 Encourage patients to get prompt treatment for

flu or other illnesses and to get vaccinated
against pneumonia or flu.
 Encourage patients to always check with their
physicians before taking any other medication,
including over-the-counter (OTC) medications.

 Perform a thorough assessment before
beginning therapy, including:
 Skin color
 Baseline vital signs
 Respirations (should be between 12 and 24
breaths/min)
 Respiratory assessment, including pulse oximetry
 Sputum production
 Allergies
 History of respiratory problems
 Other medications
 Teach patients to take bronchodilators exactly as

prescribed.
 Ensure that patients know how to use inhalers
and MDIs and have patients demonstrate use of
the devices.
 Monitor for adverse effects.

Audience Response System Question
Which medication will the nurse teach a patient

with asthma to use when experiencing an acute
asthma attack?
A. albuterol (Ventolin)
B. salmeterol (Serevent)
C. theophylline (Theo-Dur)
D. montelukast (Singulair)

 Monitor for therapeutic effects:

 Decreased dyspnea
 Decreased wheezing, restlessness, and anxiety
 Improved respiratory patterns with return to normal
rate and quality
 Improved activity tolerance
 Decreased symptoms and increased ease of
breathing

Nursing Implications:
Beta-Adrenergic Agonists
 Albuterol, if used too frequently, loses its beta2-
specific actions at larger doses.
 As a result, beta1 receptors are stimulated,
causing nausea, increased anxiety, palpitations,
tremors, and increased heart rate.

Beta-Adrenergic Agonists (Cont.)
 Ensure that patients take medications exactly
as prescribed, with no omissions or double
doses.
 Inform patients to report insomnia, jitteriness,
restlessness, palpitations, chest pain, or
any change in symptoms.

A patient with chronic bronchitis calls the office for a refill of his
albuterol inhaler. He just had the prescription filled 2 weeks ago,
but he says it is empty. When asked, he tells the nurse, “I use it
whenever I need it, but now when I use it, I feel so sick. I’ve
been needing to use it more often.” What is the most appropriate
action by the nurse?
A. The nurse should confirm the pharmacy location for the needed
refill.
B. The nurse should ask the patient to come to the office for an
evaluation of his respiratory status.
C. The nurse should tell the patient not to use this drug too often.
D. The nurse should consult the prescriber for a different inhaler
prescription.
Xanthine Derivatives
 Contraindications: history of PUD or
GI disorders
 Cautious use: cardiac disease
 Timed-release preparations should not be
crushed or chewed (cause gastric irritation).

Xanthine Derivatives (Cont.)
 Report to prescriber:
 Nausea
 Vomiting
 Restlessness
 Insomnia
 Irritability
 Tremors

Xanthine Derivatives (Cont.)
 Be aware of drug interactions with cimetidine,
oral contraceptives, allopurinol, certain
antibiotics, influenza vaccine, and others.
 Cigarette smoking enhances xanthine
metabolism.
 Interacting foods include charcoal-broiled, high-
protein, and low-carbohydrate foods.
 These foods may reduce serum levels of xanthines
through various metabolic mechanisms.

Nursing Implications: LTRAs
 Ensure that the drug is being used for chronic

management of asthma, not acute asthma.
 Teach the patient the purpose of the therapy.
 Improvement should be seen in about 1 week.

LTRAs (Cont.)
 Advise patients to check with prescriber before
taking OTC or prescribed medications to
determine drug interactions.
 Assess liver function before beginning therapy
and throughout.
 Teach patients to take medications every night
on a continuous schedule even if symptoms
improve.

Inhaled Corticosteroids
 Teach patients to gargle and rinse the mouth
with lukewarm water afterward to prevent the
development of oral fungal infections.
 If a beta-agonist bronchodilator and
corticosteroid inhaler are both ordered, the
bronchodilator should be used several minutes
before the corticosteroid to provide
bronchodilation before administration of the
corticosteroid.

Inhaled Corticosteroids (Cont.)
 Teach patients to monitor disease with a peak
flow meter.
 Encourage use of a spacer device to ensure
successful inhalations.
 Teach patient how to keep inhalers and
nebulizer equipment clean after use.

Inhalers: Patient Education
 For any inhaler prescribed, ensure that the

patient is able to self-administer the medication.
 Provide demonstration and return demonstration.
 Ensure that the patient knows the correct time
intervals for inhalers.
 Provide a spacer if the patient has difficulty
coordinating breathing with inhaler activation.
 Ensure that the patient knows how to keep track of
the number of doses in the inhaler device.

A patient is prescribed two different types of inhaled

medications for treatment of COPD. After administering the
first medication, how long should the nurse wait to
administer the second medication?
A. 1 minute
B. 5 minutes
C. 10 minutes
D. 15 minutes

Case Study
The nurse is providing teaching to a group of individuals
with COPD at a community center. Which statement by one
of the attendees indicates that further teaching is needed?
A. “If I develop a puffy face, I will stop taking

methylprednisolone (Medrol) immediately.”
B. “I will inform my prescriber of any weight gain of 2 lb or
more in 24 hours or 5 lb or more in 1 week.”
C. “I use omalizumab (Xolair) to control my asthma but not
for an acute asthma attack.”
D. “When taking theophylline (Theo-Dur), I will advise my
prescriber if I experience epigastric pain.”

Case Study (Cont.)
One of the attendees expresses concern regarding her
granddaughter’s asthma. The attendee tells the nurse that
she is afraid that she will not know which of her
granddaughter's medications to give first in case of an
asthma attack. Which medication should the nurse inform
the attendee to administer first for an acute asthma attack?
A. ipratropium (Atrovent)
B. albuterol (Proventil)
C. budesonide (Pulmicort Turbuhaler)
D. montelukast (Singulair)

Case Study (Cont.)
One of the attendees tells the nurse that he has

asthma and is being treated with a short-acting
inhaled beta2 agonist. The nurse identifies this
treatment as which step of the stepwise therapy for
the treatment of asthma?
A. Step 1
B. Step 2
C. Step 3
D. Step 4

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Chapter 37

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 Recurrent and reversible shortness of breath

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 The alveolar ducts and alveoli remain open, but

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 Continuous inflammation and low-grade

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 Air spaces enlarge as a result of the destruction

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 Relief of bronchospasm related to asthma,

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 Diminished bronchodilation when nonselective

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 Ipratropium (Atrovent), tiotropium (Spiriva), and

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 Dry mouth or throat

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 Oldest and most commonly used anticholinergic

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 Plant alkaloids: caffeine, theobromine, and

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 Leukotriene receptor antagonists (montelukast,

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 Prophylaxis and long-term treatment and

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 Known drug allergy

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 beclomethasone dipropionate (Beclovent)

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 Primary treatment of bronchospastic disorders to

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