Respiratory 2-Adrenergic Agonists Expected Action: Proto: albuterol (Proventil) Others: formoterol (Foradil), salmeterol (Serevent), terbutaline (Brethine)

) Selectively activate 2 receptors resulting in bronchodilation: bronchospasm is relieved, histamine release is inhibited, and ciliary motility is Therapeutic Uses: Albuterol: Inhaled, short-acting and oral, long-acting Formoterol, salmeterol: Inhaled, long-acting Terbutaline: Oral, L-A Adverse Effects: Inhaled: Minimal adverse effects Oral: Tachycardia/angina d/t 1 in / tremors d/t 2 in skeletal muscle Contraindications/Precautions: (C) CI: tachydysrhythmias Interactions: -blockers like propanolol negate effects of both TCAs and MAOIs risk of tachycardia and angina Education: Inhale 3-5 sec, hold 10 sec, wait 60 sec for next dose Use inhaled 2-agonist before using inhaled glucocorticoid

Methylxanthines

Expected Action: Proto: Theophylline (Theolair) Theophylline relaxes bronchial smooth muscle bronchodilation Therapeutic Uses: Long-term control of asthma Adverse Effects: Mild toxicityGI distress & restlessness. Severe reactions Severe reactions can occur at therapeutic levels and include dysrhythmias and seizures. Effects unlikely @ <20 mcg/mL. Activated charcoal absorption, lidocaine for dysrhythmias and diazepam for seizures. Contraindications/Precautions: (C) Interactions: Caffeine: CNS/ effects of theophylline. Also [theophylline] Phenobarbital, phenytoin: [theophylline] Cimetidine, ciprofloxacin: [theophylline]

Inhaled Anticholinergics

Expected Action: Proto: ipratropium (Atrovent) Others: tiotropium (Spiriva) Block muscarinic receptors on bronchi bronchodilation Therapeutic Uses: Relief of bronchospasms associated with COPD Relief of allergen-induced and exercise-induced asthma. Adverse Effects: Local anticholinergic effects Contraindications/Precautions: (B) CI: Peanut allergy Caution in narrow-angle glaucoma Education: Usual adult dose is 2 puffs (1 minute apart) If taking two inhaled medications, separate by at least 5 minutes.

Glucocorticoids Expected Action: Proto: beclomethasone (QVAR) Others: budesonide (Pulmicort), fluticasone (Flovent), triamcinolone (Azmacort), prednisone (Deltasone) Prevent inflammation, suppress airway mucous production, and promote responsiveness of 2-receptors in bronchial tree. Therapeutic Uses: Inhaled: Long-term asthma prophylaxis S-T, oral: Treat symptoms following acute asthma. L-T, oral: Treat chronic asthma 1 adrenocortical insufficiency Promote lung maturity and RDS in fetuses at risk for preterm birth. Adverse Effects: Inhaled: Dysphasia, candidiasis, bone loss Oral (10d): adrenal gland function / bone loss / hyperglycemia / glucosuria / / infection / peptic ulcer disease / myopathy / fluid & electrolyte disturbances. Contraindications/Precautions: (?) CI: Live virus / systemic fungal infect. Interactions: Diuretics: hypokalemia NSAIDs: GI ulceration Glucocorticoids counteract effects of insulin and oral hypoglycemics. Education: Oral are for short-term use, 3-10 days following acute attack.

Mast Cell Stabilizers Expected Action: Anti-inflammatory: Stabilize mast cells, inhibiting histamine release. Suppress inflammatory cells (e.g. eosinophils, macrophages) Therapeutic Uses: Prophylaxis of exercise-induced and allergen-induced asthma attacks Allergic rhinitis by intranasal route Adverse Effects: Contraindications/Precautions: Propellant CI: CAD, dysrhythmias, and status asthmaticus Education: Take 15 min before exercise Long-term prophylaxis may take several weeks

Mucolytics

Expected Action: Proto: acetylcysteine (Mucomyst) Others: hypertonic saline Enhance flow of secretions in the respiratory passages, loose thick mucosa.act like detergent. Therapeutic Uses: Acute & chronic pulmonary disease increase secretions. Cystic fibrosis Acetylcysteine is the antidote for acetaminophen poisoning Adverse Effects: Aspiration and bronchospasm Contraindications/Precautions: (B) CI: GI bleeding Caution: Peptic ulcers / esophageal varices / severe liver disease Education: Has smell of rotten eggs Dilute in fruit juice IV: Loading dose, next dose over 4h, last dose over 16h.

Antitussive Opioids Expected Action: Proto: codeine Others: hydrocodone Suppresses cough center in the medulla . Therapeutic Uses: Chronic, non-productive cough Adverse Effects: GI distress (nausea, constipation) take food, fluid/fiber CNS sedation effects: Respiratory depression (<12/min) naloxone Potential for abuse, schedule II. Contraindications/Precautions: (C) CI: acute asthma, head trauma, liver/renal dysfunction, acute alcoholism

Decongestants

Expected Action: Proto: Phenylephrine Others: Ephedrine, naphazoline, phenylpropanolamine Stimulate 1-adrenergic receptors inflammation of nasal membranes Therapeutic Uses: Allergic rhinitis, sinusitis, and common cold Adverse Effects: Rebound congestion (Max 3-5 days, taper down use) CNS stimulation (rare topical) Vasoconstriction Contraindications/Precautions: (?) CI: Chronic rhinitis Caution: CAD and hypertension Education: Oral do not lead to rebound congestion Leukotriene Modifiers Expected Action: Proto: montelukast (Singulair) Others: zileuton (Zyflo), zafirlukast (Accolate)

Prevent effects of leukotrienes thus suppressing inflammation, airway edema, bronchoconstriction, and mucus production. Therapeutic Uses: Long-term asthma therapy in folks 12 YO Adverse Effects: Liver injury zileuton and zafirlukast. (nausea, anorexia, abdominal pain) Contraindications/Precautions: (?) Interactions: Zileuton / zafirlukast inhibit warfarin metabolism [warfarin] Zileuton / zafirlukast inhibit theophylline metabolism theophylline toxicity Education: Zileuton given without regard to food. Zafirlukast taken food

General Key Points

Bronchodilators Bronchodilators Anti-inflammatory Anti-inflammatory

2-adrenergic agonists Inhaled, short-acting

Glucocorticoids Inhaled medications

Albuterol (Proventil, Ventolin)

Inhaled, long-acting Oral, long-acting

Formoterol, salmeterol Albuterol, terbutaline

Beclomethasone (QVAR) Budesonide (Pulmicort) Fluticasone (Flovent) Triamcinolone (Azmacort)

Oral medications

Prednisone, prednisolone Cromolyn & nedocromil (inhaled) Leukotriene modifiers (Oral)

Montelukast (Singulair) Zafirlukast (Accolate)

Methylxanthines Oral, long-acting

Theophylline
Anti-cholinergics Maintenance therapy

Ipratropium, inhaled (Atrovent)

Bronchodilators are oral or inhaled, for acute relief, short-term

prophylaxis and long-term control. Anti-inflammatory are for longacting prophylaxis.

Trade Name: Metaproterenol Classification: Beta2 Adrenergic Agonists Use(s): To treat bronchospasm, asthma, to promote bronchodilation Action: Relaxation of smooth muscle of bronchi Route of Admenstaion: orally (onset 15 mint) or by inhalation (onset is 1 mint) (for long term asthma) Contraindications: Hypersensitiivity, cardiac dysrhythmias, Glaucoma, cardiac disease, hypertension. Side Effects: nervousness, tremors, restlessness, insomnia, hyperglycemia, nausea muscle cramping in extremities. palpitation, seizures

Nursing implications/teaching :Take this drug with empty stomach.or 1-2 hours before meal. NO Smoking

Trade Name: ipratropium (Atrovent) Others: tiotropium (Spiriva) Classification: Alpha Beta2 Adrenergic Agonists

Use(s): Relief of bronchospasms associated with COPD

Relief of allergen-induced and exercise-induced asthma

Action: Block muscarinic receptors on bronchi bronchodilation Contraindications: Peanut allergy , use with caution glaucoma patients.

Side Effects: Local anticholinergic effects Nursing implications/ teaching: Usual adult dose is 2 puffs (1 minute apart)

If taking two inhaled medications, separate by at least 5 minutes

Trade Name: Theophylline Classification:
Use(s): for chronic stable asthma and COPD. Action: Relaxes the smooth muscle of bronchi, bronchioles and pulmonary blood vessels by inhibiting the enzymes Phosphosdiesterase, increased cAMP= bronchilation. ; target range 10-20 mcg/ml Contraindications: Not good for seizures disorders, cardiac renal or liver disease.

Side Effects: restlessness , tachycardia, tremor, hypotension, seizure insomnia, agitation, cramps, brain damage. Severe in children than adult. Nursing implications: administer IV for acute asthmatic attack,(*dilute for iv) For oral, take with food to avoid GI distress. To avid side effect, not take other xanthines while taking theophylline. For aminophylline (a product of theophylline) IV MUST administer SLOWLY via infusion rate.

Expected Action: Proto: acetylcysteine (Mucomyst) Others: hypertonic saline Enhance flow of secretions in the respiratory passages, loose thick mucosa.act like detergent.

Trade Name: acetylcysteine (Mucomyst) Classification: Use(s): Acute & chronic pulmonary disease increase secretions. Cystic fibrosis Acetylcysteine is the antidote for acetaminophen poisoning (if admint within 12 -24 hours) Action: Enhance flow of secretions in the respiratory passages, loose thick mucosa. Act like detergent. Contraindications: CI: GI bleeding Caution: Peptic ulcers / esophageal varices / severe liver disease Side Effects: nausea, vomiting,stomataics , and running nose. Adverse effect Aspiration and bronchospasm Nursing implications: Has smell of rotten eggs , Dilute in fruit juice
IV: improvement withing 3 to 7 days.

Interaction with drug/Food :

Trade Name: Montelukast Classification: Bronchodilator : Leukotriene receptor antagonist. Use(s): for the prevention and maintenance treatment of asthma Action: bind with leukotriene receptors to inhibit smooth muscle contraction and bronchoconstriction. Contraindications: Hypersensitivity, severe asthma attack, status asthmaticus, Severe LIVER disease. Side Effects: fever, headache, dizziness, fatigue,nasal congestion,cough,sore throat,dental pain,influenza,dyspepsia, abdominal pain ,rash.

Nursing implications/Teaching: Not take montelukast with St.johns wart without the advise of doctor. Not with black orgreen tea, guarana and zalfirlukast. Stop smoking. Check if patient (only children) history of phenylketonuria. Interaction with Drug/Food/Lab: Abnormal liver function tests.(ALT-AST)

Glucocorticoids

Generic Name Action:Proto: beclomethasone (QVAR) Others: budesonide (Pulmicort), fluticasone (Flovent), triamcinolone (Azmacort), prednisone (Deltasone) Anti intiinflammatory action, suppress airway mucous production, and promote responsiveness (synergetic effect with) of 2-receptors in bronchial tree. Uses: Inhaled: Long-term asthma prophylaxis, not helpful for severe asthma attack. Reduce bronchial hyper responsiveness. S-T, oral: Treat symptoms following acute asthma. L-T, oral: Treat chronic asthma. Promote lung maturity and decrease RDS in fetuses at risk for preterm birth. Adverse Effects: Inhaled: Dysphasia, candidiasis, bone loss Oral (10d): decrease adrenal gland function / bone loss / hyperglycemia / glucosuria / / infection / peptic ulcer disease / myopathy / fluid & electrolyte disturbances. Contraindications/Precautions:: Live virus / systemic fungal infect. Interactions: Diuretics: hypokalemia NSAIDs: GI ulceration Glucocorticoids counteract effects of insulin and oral hypoglycemics. Education: Oral are for short-term use, 3-10 days following acute attack.
Interaction with Drug/Food/Lab : should take with food to avid ulceration.

Decongestants
Trade Name: Phenylephrine Others: Ephedrine, naphazoline, phenylpropanolamine Classification: Use(s): Allergic rhinitis, sinusitis, and common cold Action: Stimulate 1-adrenergic receptors inflammation of nasal membranes Contraindications:

Side Effects: Rebound congestion (Max 3-5 days, taper down use)
CNS stimulation (rare with topical )Vasoconstriction Nursing implications/Teaching: Oral do not lead to rebound congestion, Chronic rhinitis Caution: CAD and hypertension

Interaction with Drug/Food/Lab

Expected Action: Proto: codeine Others: hydrocodone

Suppresses cough center in the medulla oblongata.

Trade Name: Antitussive Opioids codeine Others: Guaifensin (Robitussin) Classification: Use(s): Chronic, non-productive and irritating cough Action: Suppresses cough center in the medulla, reduce viscosity of tenacious. Contraindications: acute asthma, head trauma, liver/renal dysfunction, acute alcoholism Side Effects: Drowsiness, GI distress (nausea, constipation)
Potential for ABUSE , schedule II.

Nursing implications/Teaching : take with food, IINCREASED fluid/fiberCNS sedation effects:

Respiratory depression (<12/min) naloxone

Trade Name: Robitussin Classification: Use(s): Action: loose Contraindications:

Side Effects: Adverse Effect Nursing implications/ Teaching Drug/Food/Lab Interactions.

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