Drugs for Asthma and Other Pulmonary Disorders

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Drugs for Asthma and Other Pulmonary Disorders

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1. Drugs for Asthma and Other Pulmonary Disorders Chapter 39

2. Lower Respiratory Tract

3. Lower Respiratory Tract The autonomic nervous system control Discuss stimulation of sympathetic (adrenergic) nerves Discuss stimulation of parasympathetic (cholinergic) nerves What is the relevance of this information in regards to pharmacotherapy of the lower respiratory tract?

4. Inhalation Drug Administration What is the primary advantage to administering drugs via inhalation? Describe the mechanism of aerosolized therapy. Discuss the potential for systemic effects of inhalation agents.

5. Devices used for Aerosol Therapy Nebulizer Metered Dose Inhaler (MDI) Dry Powder Inhaler (DPI) Discuss the mechanism of delivery for these devices. Discuss the disadvantages of Aerosol therapy.

6. Chronic Airflow Limitation Disorders Asthma Chronic Bronchitis Pulmonary Emphysema Discuss the pathophysiology of obstructive airway disease. Identify characteristic symptoms associated with chronic airflow limitations.

9. Pharmacotherapy for Asthma What pharmacologic drug class would you expect for termination of an asthma attack? Describe the mechanism of action for the pharmacologic drug class. Identify associated therapeutic classifications.

10. Beta-adrenergic Receptor Agonists What is the benefit of beta-receptor agonists? Which beta receptor is most selective for sympathetic target organs except the heart? What is the benefit of the development of selective beta-receptor agonists?

11. Classification of Beta-adrenergic Receptor Agonists

12. Inhalation vs. Oral Therapy Compare and contrast inhalation and oral therapy with Beta-adrenergic Receptor Agonists. Discuss systemic side effects associated with oral administration.

13. Case Study John, an 18 year-old has had asthma since he was 6 years old. He treats his asthma with daily oral bronchodilators and has inhalers for acute episodes. He has come to your clinic and states he has needed to increase the use of his albuterol inhaler over the last three days. What does this mean?

15. Beta2-adrenergic Receptor Agonist- Nursing Considerations Assess Vital Signs: Assess indicators of oxygenation: Respiratory rate Heart rate Lung sounds Respiratory effort Skin color SpO2 Use carefully: Limited use in children < 6 Contraindicated: Hx: MI or dysrhythmia Breastfeeding

16. Beta2-adrenergic Receptor Agonists- Key Patient Teaching Immediately report: Difficulty breathing, palpitations, tremors, vomiting, nervousness, or vision changes Use inhaler correctly: Hold breath 10 seconds after inhaling med Wait 2 minutes between inhalations Rinse mouth after use Take as prescribed.

17. Alternative Bronchodilators Anticholinergics Ipratropium bromide (Atrovent) Tiotropium (Spiriva) Describe the mechanism of action of these drugs. Discuss the benefits to inhaled administration of these drugs.

18. Anticholinergics- Nursing Considerations Assess RR before and after 1st dose Assess VS and indicators of oxygenation Use cautiously: Narrow angle glaucoma, BPH, renal disorders, urinary bladder neck obstruction Children < 2 (ipratropium), < 1 (tiotropium) Not recommended: Breastfeeding

19. Anticholinergics- Patient Teaching Do not use for rescue Wait 5 minutes between meds Avoid contact with eyes Rinse mouth after inhaling Correctly use inhaler Report: Changes in urinary pattern Change in color or amount of sputum Unsatisfactory relief of symptoms

20. Methylxanthines Alternative bronchodilators Theophylline Aminophylline Narrow margin of safety Numerous drug-drug interactions Common side effects Given the concerns about methyl-xanthines, discuss why they may still be prescribed.

21. Methylxanthines- Nursing Considerations Assess VS and indicators of oxygenation Monitor for toxicity Use cautiously in elderly and children Not recommended if breastfeeding Contraindicated: CAD, Angina Pectoris Severe renal or liver disorders, peptic ulcers BPH, diabetes mellitus

22. Methylxanthines- Patient Teaching Limit caffeine Report early s/s of toxicity Take as prescribed Limit/avoid cigarettes Increase fluids Avoid OTC cold meds Keep scheduled follow-up and lab appointments Report unsatisfactory symptom relief

23. Glucocorticoids- Review Describe the therapeutic effect of glucocorticoid administration. Identify the organ that produces endogenous glucocorticoids. Discuss anticipated adverse reactions to glucocorticoid therapy.

24. Glucocorticoids Compare and contrast intranasal and oral glucocorticoid medication administration.

25. Glucocorticoids- Nursing Considerations Monitor VS and oxygenation indicatiors Assess for s/s of infection Use cautiously: HTN, GI disease, CHF, VTE disease Not recommended: Pregnant or breastfeeding Not a rescue med Rinse mouth after use Diabetics: closely monitor glucose

26. Glucocorticoids: Patient Teaching Daily temp and BP, weekly weight Instruct re: S/S of infection Proper use and care of inhalation devices Report: Tarry stools, edema, dizziness, difficulty breathing Increased incidence of asthma symptoms Potassium rich foods Take as prescribed No ASA

28. Leukotrienes What are leukotrienes? What is the physiologic effect of leukotriene release in airways? What is the role of Leukotriene Modifiers?

29. Leukotriene Modifiers Zileuton (Zyflo) Zarfilukast (Accolate) Monteleukast (Singulair) Compare and contrast the mechanism of action of these leukotriene modifiers. Discuss anticipated side effects.

30. Leukotriene Modifiers- Nursing Considerations Monitor VS and oxygenation indicators Monitor CBC and periodic LFTs Assess for s/s of infection Not a rescue med Monitor for s/s of liver toxicity and flu-like symptoms Contraindicated: Alcohol abusers Pregnant women < 1 year of age

31. Leukotrienes- Drug-Drug Considerations Warfarin Closely monitor PT and INR Phenytoin Closely monitor phenytoin level Theophylline Decrease theophylline dose and closely monitor zileuton levels Phenobarbital Monitor effectiveness of monteleukast Propranolol Closely monitor HR and BP

32. Leukotrienes- Patient Education Take as prescribed- even if asymptomatic Not a rescue med Immediately report s/s of liver dysfunction. Keep all scheduled follow-up and lab visitis Report unsatisfactory relief Avoid breastfeeding

33. Mast Cell Stabilizers What is the role of mast cells in the immune response? What is the mechanism of action of Mast Cell Stabilizers? Discuss the implications for asthma pharmacotherapy. Compare and contrast cromolyn and nedocromil.

35. Chronic Obstructive Pulmonary Disease What two primary pulmonary disorders are included in the classification of COPD? Describe characteristic symptoms associated with COPD. Identify a diagnostic test used to assist with diagnosis of COPD.

37. Chronic Bronchitis Describe the pathophysiology of chronic bronchitis? What early sign(s) would you anticipate? What additional clinical signs would be noted through history and physical examination? Identify a common recurrent problem. Identify expected comorbid conditions.

39. Chronic Bronchitis Identify the signs and symptoms of chronic bronchitis and discuss why these occur.

41. Emphysema Describe the pathophysiology of emphysema. Discuss the two etiologies of emphysema. Extrinsic Intrinsic

42. Emphysema Discuss the signs and symptoms you would anticipate with emphysema and discuss why.

44. Case Application (Thanks Professor Parsons) At this moment, you are a nurse on a medical-surgical intermediate care unit. You have just received a patient with an acute exacerbation of COPD from the ED. John is a 64-year-old male admitted to the hospital with increased cough, sputum production, and dyspnea. Medical History: 40 pack year smoking history, COPD, diabetes.

45. Case Application Continued Assessment data Vitals: HR 84, BP 150/64, RR 26, T 97.6° F, 87% RA Respirations labored and irregular, wheezes bilateral A & O X 3 but visibly fatigues Last influenza vaccine 6 months ago Pneumococcal vaccine 2 years ago John’s wife tells you that they just returned home from visiting their grandchildren who were both ill.

46. Case Application Continued You recognize that adequate oxygenation is an immediate treatment goal in an exacerbation of COPD. You place John on 2L nasal cannula oxygen. Describe the assessment data that supports an exacerbation of COPD. John’s wife is visibly upset. She states “how could this happen. He takes his medications.” How would you respond to his wife?

47. Case Application Continued Next, you review John’s admission medication orders. You are not surprised by the orders because you know the role of these medications in optimizing lung function. albuterol 2.5 mg q 4 hrs and q 1 hr prn Atrovent 500 mcg q 4 hrs prednisone 40 mg daily levofloxacin 500 mg daily

48. Case Application Continued What is the therapeutic and pharmacologic class of albuterol? Describe the mechanism of action. Discuss route(s) of delivery. Identify key side effects Identify precautions for use

49. Case Application Continued What is the therapeutic and pharmacologic class of ipratropium (Atrovent)? Describe the mechanism of action. Discuss route(s) of delivery. Identify key side effects Identify precautions for use

50. Case Application Continues What physical assessment data will you collect prior to albuterol and Atrovent administration? What follow-up actions would you take to ensure the effectiveness of therapy?

51. Case Application Continued What is the therapeutic and pharmacologic class of prednisone? Describe the mechanism of action. Discuss route(s) of delivery. Identify key side effects Identify precautions for use

52. Case Application Continued prednisone Route of Administration: The efficacy of oral glucocorticoids is comparable to that of intravenous therapy. When might an intravenous agent (methylprednisolone/Solu-Medrol) be used?

53. Case Application Continued Antibiotics The most common bacterial pathogens (H. influenza, M. catarrhalis, S. pneumoniae) are difficult to isolate in sputum Antibiotics improve clinical outcomes in patients with moderate or severe exacerbation. Others: trimethoprim-sulfamethoxazole (Bactrim), piperacillin-tazobactam (Zosyn), ceftriaxone (Rocephin)

54. Case Application Continued You arrive on the unit later in the week to find John has discharge orders. You know that he will be returning home on prednisone, as well as albuterol and Atrovent (inhalers). Explain the medication education you will give John and his wife about prednisone. What else is important in his discharge plan?

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