Chapter 55:

Drugs Acting on the Lower

Respiratory Tract

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Changes in the Airway With COPD

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Manifestations of COPD

 Air is trapped in the lower respiratory tract

 The alveoli degenerate and fuse together
 The exchange of gases is greatly impaired

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Prevention and Treatment for COPD

 Reduce environmental exposure to irritants

 Smoking cessation
 Filter allergens from the air
 Avoid exposure to known irritants and allergens
 Open the conducting airways through muscular
bronchodilation
 Decrease the effects of inflammation on the airway lining

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Adult Respiratory Distress Syndrome
(ARDS)

 Characteristics
o Progressive loss of lung compliance and increasing
hypoxia
 Causes
o Cardiovascular collapse; major burns; severe
trauma; rapid depressurization
 Treatment
o Reversal of the underlying cause combined with
ventilatory support

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Use of Lower Respiratory Tract Agents
Across the Lifespan

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Xanthines #1

 Facilitate respiration by dilating the airways

o Include two categories
Sympathomimetics and Anticholinergics
o Aminophylline (generic)
o Caffeine (Caffedrine, and others)
o Dyphylline (generic)
o Theophylline (generic)

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Xanthines #2

 Actions
o Direct effect on the smooth muscles of the respiratory
tract, both in the bronchi and in the blood vessels
 Indications
o Symptomatic relief or prevention of bronchial asthma and
for reversal of bronchospasm associated with COPD
 Pharmacokinetics
o Narrow therapeutic margin
o Rapidly absorbed for the GI tract
o Metabolized in the liver and excreted in the urine

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Xanthines #3

 Contraindications
o GI problems, coronary disease, respiratory dysfunction,
renal or hepatic disease, alcoholism, or hyperthyroidism
 Adverse Effects
o Related to theophylline levels in the blood
o GI upset, nausea, irritability, and tachycardia to seizure,
brain damage, and even death
 Drug-to-Drug Interactions
o Many drugs interact with xanthines
o Nicotine increases the metabolism

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Nursing Considerations for Xanthines

 Assess:
o History and Physical Exam and known allergy
o Peptic ulcer, gastritis, renal or hepatic dysfunction,
and coronary disease
o Monitor blood pressure, pulse, cardiac auscultation,
peripheral perfusion, and baseline electrocardiogram
o Skin, BS, liver and renal function, appropriate lab
values, as well as theophylline levels

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Prototype Xanthines #1

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Prototype Xanthines #2

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Sympathomimetics #1

 Mimic the effects of the sympathetic nervous system.

One of the actions of the sympathetic nervous system is
dilation of the bronchi with increased rate and depth of
respiration
o Albuterol (Proventil HFA, and others),
o Arformoterol (Brovana)
o Rphedrine (generic)
o Epinephrine
o (EpiPen), formoterol (Foradil) and more.

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Sympathomimetics #2

 Actions
o Beta2 selective adrenergic agonists
 Indications
o Acute asthma attach
o Bronchospasm in acute or chronic asthma
o Prevention of exercise-induced asthma
 Pharmacokinetics
o Rapidly distributed after injection, transformed in the liver to
metabolites that are excreted in the urine
 Contraindications
o Depends on the severity of the underlying condition

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Sympathomimetics #3

 Adverse Effects
o Sympathomimetic stimulation
o CNS stimulation
o GI upset, cardiac arrhythmias, hypertension,
bronchospasm, sweating, pallor, and flushing
 Drug-to-Drug Interactions
o General anesthetics

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Nursing Considerations for
Sympathomimetics

 Assess:
o History and Physical Exam and known allergy
o Cigarette use, pregnancy and lactation
o Cardiac disease, vascular disease, arrhythmias,
diabetes, and hyperthyroidism
o Reflexes and orientation, VS, reflexes and orientation
and appropriate lab values

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Prototype Sympathomimetics #1

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Prototype Sympathomimetics #2

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Question #1

Please answer the following question as true or false.

The adverse effects of the Xanthines are related to

theophylline levels in the blood and include brain
damage.

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Answer to Question #1

True

Rationale: Adverse Effects: Related to theophylline levels

in the blood; GI upset, nausea, irritability, and
tachycardia to seizure, brain damage, and even death.

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Anticholinergic #1
 Patients who cannot tolerate the sympathetic effects of
the sympathomimetic might respond to the
anticholinergic drugs
o Ipratropium (Atrovent)
o Tiotropium (Spiriva)
o Aclidinium (Tudorza Pressair)
o Umeclidinium (Incruse, Ellipta)

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Anticholinergic #2
 Actions
o Anticholinergic that blocks vagally mediated reflexes
by antagonizing the action of acetylcholine
 Indications
o Maintenance treatment of bronchospasm associated
with COPD
 Pharmacokinetics
o Onset of action is 15 minutes when inhaled
o Peaks in 1-2 hours, duration of action is 3-4 hours

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Anticholinergic #3

 Caution
o Any condition that would be aggravated by the
anticholinergic effects of the drug
 Adverse Effects
o Related to the anticholinergic effects of the drug
o Dizziness, headache, fatigue, nervousness, dry
mouth, sore throat, palpitations, and urinary
retention

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Nursing Considerations for Anticholinergic

 Assess:
o History and Physical Exam and known allergy
o Acute bronchospasm, bladder neck obstruction or
prostatic hypertrophy, orientation, affect, and
reflexes
o Pulse and B/P, respirations and adventitious sounds
and urinary output

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Prototype Anticholinergics

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Inhaled Steroids #1

 Very effective treatment for bronchospasm

o Beclomethasone (Beconase AQ)
o Budesonide (Pulmicort Respules, Pulmicort Flexhaler)
o Ciclesonide (Alvesco)
o Fluticasone (FloventDiscus, Flovent HFA)
o Triamcinolone (generic)

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Inhaled Steroids #2

 Actions
o Decrease the inflammatory response in the airway
Indications
o Prevention and treatment of asthma
o Treat chronic steroid-dependent bronchial asthma
 Pharmacokinetics
o Well absorbed from the respiratory tract
o Metabolized by natural systems, mostly within the liver,
excreted in the urine

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Inhaled Steroids #3
 Contraindications
o Not used for emergency during an acute attack or status
asthmaticus
o Pregnancy or lactation
 Adverse Effects
o Sore throat
o Hoarseness
o Coughing
o Dry mouth
o Pharyngeal and laryngeal fungal infections

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Nursing Considerations
for Inhaled Steroids

 Assess:
o History and Physical Exam and known allergy
o Systemic infections, pregnancy and lactation
o VS, respirations, adventitious sounds, nares

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Prototype Inhaled Steroids

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Leukotriene Receptor Antagonists #1

 Act more specifically at the site of the problem

associated with asthma
o Zafirlukast (Accolate)
o Montelukast (Singulair)
o Zileuton (Zyflo)

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Leukotriene Receptor Antagonists #2

 Actions
o Selectively and competitively block or antagonize receptors for
the production of leukotrienes
 Indications
o Prophylaxis and chronic treatment of bronchial asthma in adults
and in patients younger than 12 years of age
 Pharmacokinetics
o Rapidly absorbed from GI tract, extensively metabolized in the
liver and primarily excreted in feces
 Caution
o Hepatic or renal impairment
o Pregnancy and lactation

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Leukotriene Receptor Antagonists #3

 Adverse Effects
o Headache, dizziness, myalgia, nausea, diarrhea and
abdominal pain, elevated liver enzyme
concentrations, vomiting, and generalized pain
 Drug-to-Drug Interactions
o Propranolol, theophylline, terfenadine, or warfarin
o Calcium channel blockers, cyclosporine, or aspirin

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Nursing Considerations for Leukotriene
Receptor Antagonists

 Assess:
o History and Physical Exam and known allergy
o Acute bronchospasm or asthmatic attack
o Impaired renal or hepatic function
o Temperature, orientation and affect

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Prototype Leukotriene Receptor
Antagonists

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Lung Surfactants #1

 Naturally occurring compounds or lipoproteins containing

lipids and apoproteins that reduce the surface tension
within the alveoli, allowing expansion of the alveoli for
gas exchange
o (Survanta), calfactant
o (Infasurf), the newest drug of the class
o Lucinactant (Surfaxin)
o Poractant (Curosurf)

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Lung Surfactants #2

 Actions
o Replace the surfactant that is missing in the lungs of
neonates with RDS
 Indications
o Rescue treatment of infants who have developed
RDS
 Pharmacokinetics
o Begin to act immediately on instillation into the
trachea
o Metabolized in the lungs

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Lung Surfactants #3

 Contraindications -Emergency drug; no contraindication

 Adverse Effects
o Patent ductus arteriosus
o Hypotension
o Intraventricular hemorrhage
o Pneumothorax
o Pulmonary air leak
o Hyperbilrubinemia
o Sepsis

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Nursing Considerations
for Lung Surfactants

 Assess:
o History and Physical Exam and known allergy
o Time of birth and exact weight
o Temperature, Respirations, adventitious sounds,
endotracheal tube placement and patency, and chest
movements
o Blood pressure, pulse, and arterial pressure
o Blood gases and oxygen saturation

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Prototype Lung Surfactants

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Mast Cell Stabilizers

 Actions-
o Works at the cellular level to inhibit the release of
histamine and inhibits the release of SRSA
 Indications-Treatment of chronic bronchial asthma
o Exercise induced asthma
o Allergic rhinitis
o It is no longer considered part of the treatment
standards because of the availability of more specific
and safe
o Cromolyn (NasalCrom)

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Question #2

Which of the following is a contraindication to using lung

surfactants?
A. Prematurity
B. Older adult
C. No contraindications
D. COPD

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Answer to Question #2

C. No contraindications

Rationale: Because lung surfactants are used as

emergency drugs in the newborn, there are no
contraindications.

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Question #3

The nurse is caring for a patient taking Budesonide.

What would be an appropriate nursing diagnosis for this
patient?
A. Risk for injury related to immunosuppression
B. Risk for injury related to CNS effects
C. Risk for injury related to CVS effects
D. Risk for injury related to age and risk of infection

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Answer to Question #3

A. Risk for injury related to immunosuppression

Rationale: Nursing diagnoses related to drug therapy

might include: risk for injury related to
immunosuppression; acute pain related to local effects
of the drug; deficient knowledge regarding drug therapy.

Copyright © 2017 Wolters Kluwer • All Rights Reserved