• asthma, chronic bronchitis, emphysema and combinations of these.  
• Also bronchiectasis which is some sort of pulmonary collapse.  
• Causes DYSPNEA (difficulty breathing) and interference with gas exchange at alveoli.
• Patients are easily fatigued, have frequent lung infections from difficulty removing mucus and excess mucus, 
• use of accessory muscles, othopneic, are usually thin, pursed lip breathing to try to suck in air, barrel chest
• Often have “hypoxic drive” meaning they are usually lower O2 sat. and ok there.
• Usually no wheezing; shallow breaths with crackles

• sympathomimietic (works on adrenergic receptors and sympathetic NS)

2 major categories of asthma meds:

1. Long-term control – LABAs - amounts and types of drugs depend on severity of asthma (“Step Care Approach”) – most effective types of drugs are the ones that reduce inflammation

2. Quick relief – include SABAs, cholinergic blocking drugs, and oral steroids

a.       ADRENERGIC/SYMPATHOMIMETIC BRONCHODILATORS – these stimulate beta-adrenergic receptors (parasympathetic) resulting in bronchdilation; they are beta₂ receptor agoists. They are either short-acting or long acting:

1.      Short-acting beta2 agonists (SABAs) for acute symptom relief

a.       Albuterol

b.      Ephedrine

c.       Epinephrine (Primatene Mist)

d.      Bitolterol

e.       Levalbuterol

f.        Metaproterenol

g.       Pirbuterol (Maxair)

h.       Terbutaline

2.      Long-acting beta2 agoists (LABAs)

a.       arformoterol

b.      formoterol

c.       salmeterol (Serevent)

b.      XANTHINE DERIVATIVE BRONCHODILATORS = methylxanthines; used to be the drug of choice but have lots of unteractions!

1.      aminophylline

2.      dyphylline

3.      oxtriphylline

4.      theophylline

                                                   i.      relaxes smooth muscle around bronchi relieving respiratory distress

1.      asthma

2.      exercise induced bronchospasm (EIB)

3.      bronchitis

4.      emphysema

5.      COPD

a.       SABAs – headache, dizziness, nervousness, throat irritation, drug tolerance, tachycardia, dysrrhythmia, hypoklemia, hyperglycemia

2.      CV – tachycardia, palpitations, arrythmias

3.      Nervousness, insomnia

4.      If too much, can actually cause a bronchspasm

LABAs may increase risk of asthma related death, so not 

1.      known hypersensitivities

2.      arrythmias associated with tachycardia

3.      brain damage

4.      cerebral arteriosclerosis

5.      narrow angle glaucoma

6.      Salmeterol not to be used during acute bronchospasm

1.      use caution in pts with HT, cardiac dysfunction, hyperthyroidism, glaucoma, diabetes, prostate hypertrophy, seizure hx

2.      Preg cat C except terbutaline is a B

                                                   i.      (think cardiovascular)

1.      adrenergic drugs – additive adrenergic effects

2.      tricyclics – hypotension

3.      B blockers – the adrenergic is inhibited

4.      methyldopa – hypotension

5.      oxytocic drugs – hypotension possibly severe

6.      theophyline – up risk cardiotoxicity

                                                   i.      stimulatesCNS to dilate bronchi by relaxing smooth muscle around bronchi

1.      prevention of asthma and symptomatic relief

2.      bronchospasm of chronic bronchitis and emphysema

1.      CNS – reslessness, irritability, headache, nervousness, tremor

2.      Cardiac/Resp – tachycardia, palpitations, ECG changes, increased respirations; arrythmias

3.      Other – N/V, fever, hyperglycemia, flushing and alopecia

1.      known hypersensitivity

2.      peptic ulcers

3.      seizures unless well controlled

4.      serious uncontrolled arrythmias

1.      use cautiously in pts with cardiac disease or other heart conditions

2.      caution with liver disease, alcohol abusers, elderly

3.      Preg cat C.

1.      theophylline seems to have the most (or only) interactions – 21 are listed!  The only interactions the book describes, however, are with

a.       nicotine, causing decrease in theophylline levels and

b.      oral contraceptives causing increased theophylline levels. 

2.      No interactions are listed for the other xanthine derivitives

a.       INHALED CORTICOSTEROIDS (ICSs) – are the most consistently effective tx for long-term control for all levels of asthma

1.      beclomethasone

2.      budesonide

3.      flunisolide

4.      fluticasone (Flovent)

5.      mometasone

6.      trimcinolone

7.      ICS/LABA combinations (when stepping up treatment)

a.       Budesonide/fomotorol (Symbicort)

b.      Fluticasone/salmeterol (Advair)

b.      MASTCELL STABILIZERS

1.      cromolyn

2.      nedocromil

c.       LEUKOTRIENE MODIFIERS and IMMUNOMODULATORS – some are

1.      leukotrine receptor antagonists – block leaukotrines

a.       montelukast (Singulair)

b.      zafirlukast

2.      leukotrine formation inhibitor – prevents formation of leukotrines

a.       zileuton

3.      monoclonal antibody (immunomodulator) – prevents binding of immunoglobulin to receptors on mast cells (and other inflame cells), limiting allergic reaction; these are the drugs for very severe asthma (moderately severe to severe persistent)

a.       omalizumab – given subcut (SC) q 2-4 wks

                                                   i.      anti-inflams that reduce number of mast cells, blocking allergic reaction.  These drugs also increase sensitivity of beta2 receptors which increased effectiveness of the beta2 receptor agoists

1.      mngmt and prophylaxis of inflammation of chronic asthma.

2.      Some are used for nasal polyps and rhinitis (have different trade names for same generic)

a.       Beclomethasone

b.      Budesonide (Rhinocort)

c.       Flunisolide

d.      Fluticasone (Flonase)

e.       Mometasone monohydrate (Nasonex)

f.        Triamcinolone acetonide (Nasacort)

                                                   i.      less likely with inhilatinos vs oral admin; reactions include

1.      throat irritation

2.      hoarseness

3.      URIs

4.      Fungal infections of mouth and throat

5.      Supressed HPA function (interesting)

6.      cough

7.       vertigo

8.      headache

2.      acute bronchospasms or acute asthma attacks (status asthmaticus e.g.) [use bronchodilator]

1.      comprised immunity

2.      glaucoma

3.      kidney disease

4.      liver disease

5.      convulsive disorders

6.      diabetes

7.      Combining ICSs with systemic corticosteroids can up risk of HPA suppressions, resulting in adrenal insufficiency

8.      Preg cat C

9.      Patient deaths can occur from adrenal insufficiency when transferred from systemic to inhaled corticosteroid

1.      Ketacozanole may increase plasma levels of budesonide and fluticasone

                                                   i.      not fully understood, thought to stabilize the mast cell membrane preventing release of inflammatory mediators like histamine and LEUKOTRINES (inflammatory mediator released by mast cell); are antinflammatories

                                                   i.      in conjunction with other drugs for asthma and allergies.  Also used to prevent Exercise Induced Bronchospasm.

1.      throat irritation and dryness

2.      unpleasant taste sensation

3.      cough or wheeze

4.      nausea

5.      dizziness headache

1.      known hypersensitivities

2.      don’t use during acute attacks of asthma b/c may worsen bronchospasm

3.      preg cat b

4.      cautious used in renally/hepatically impaired

                                                   i.      antinflammatory -  leukotrines released by mast cells during asthma are primarily responsible for bronchconstriction.  So, by blocking or preventing them, allergic reaction is reduced

1.      headaches

2.      flu-like symptoms

3.      the immunomodulators can cause anaphylaxis

1.      known hypersensitivity

2.      don’t use for acute attacks

3.      don’t use with liver disease (zileuton)

4.      preg cats B and C

                                                   i.      when leukotrine modifiers admin with

1.      aspirin – increases level of zafirlukast

2.      warfarin – up anticoagulant effect

3.      theophylline – decreases zafirlukast and increases zileuton

4.      erythromycin – decresed zafirlukast

All always have a SABA (rescue inhaler)

Start with low dose ICSs

Add LABA

Add immunomodulator

Add oral corticosteroid

This is not exact, but basically

1.      preadmin – assess symptoms carefully, in part to determine if acute (treated differently); also check family hx b/c asthma tends to be familial

a.       For acute distress – take vitals, listen to lungs, note dyspnea, cough, wheezing, etc, use of accessory muscles, describe sputum, signs of hypoxia including confusion and restlessness; note respiratory rate and heart rate (will be higher, need point of comparison)
Ask about triggers of attach

b.      For Long-Term management – askabout allergies, requency of attacks, severity, triggers, medication hx of asthma drugs

2.      Post admin

a.       For acute attack, assess status q 4 hours at least and when drug administered.  Not rate, sounds, accessory muscles
Keep record of in/out fluid

b.      For chronic – monitor heart and pts with  hx of cv problems for chest pain and changes in ECG

a.       Careful monitoring

b.      Give with food or milk if GI upset

c.       Pt is started at lowest amount of meds (step system which goes both ways, i.e. meds will be removed as sxs improve)

d.      Provide emotional support for frequent changes of meds

e.       For acute sxs help with SABA bronchodilator up to 3 txs at 20 min intervals
Epinephrine may be ordered for acute bronchospasms, exercise great care wihen reading order and preparing drugs bc doses are extremely small (error prevention).  Epi. Is given by subcut injection

f.        If using a xanthine dirivitive for acute attack, may need to cause THEOPHYLLINIZATION – dose is initially higher (loading dose) to bring to therapeutic range fast (vs days).  Must monitor for theophylline toxicity

                                                                                                                           i.      THEOPHYLLINE TOXICITY – anorexia, N/V diearrhea, confusion, ab cramps, headache, restlessness, insomnia, tachycardia, arrythmias, seizures

                                                                                                                         ii.      If theophylline levels go above 20mcg/mL report (too high, normal range for therapeutic effect is 10-20mcg/mL

g.       Older adults taking adrenergic bronchodilators at increased risk for adv rxs r/t both CV system (arrythmias, palpitations, HT and tachycardia) andCNS (restlessness, agitation, insomnia)

h.       For long-term control, goal is reducing inflammation of mucosa.

i.         Children taking corticosteroids may slow growth, informPCP if notice, esp. during puberty

j.        Calcium or vit D may be prescribed for elders at risk of ostoporosis

k.      LABA drugs do not replace fast acting drugs

l.         Teach pt how to use metered dose inhaler or dry-powder inhaler

m.     Formotorol comes in a capsule that is to be inhaled, tell pt not to swallow

n.       Mast cell stabilizers come in ampules with liquid to mix ONLYL WITH WATER

o.      Leukotrine receptor antags/inhibitors or immunomodulators NEVER USED FOR ACUTE ATTACK CAN MAKE WORSE

p.      Zileuton may cause liver damage, pt report sxs of liver dysfunction like pain at liver, jaundice, fatigue

q.      For monoclonal antibodies administered subcut in clinic, tell pt that bad reactions can take up to 4 days and have emergency contact close at hand

a.       Anxiety – can be the breathlessnessAND the drugs administered.  Tell pt that drug will work shortly, be calm, monitor BP/HR.  Explain that adrenergic drug may be causeing anxiety, migh help some.

b.      Ineffective Airway Clearance – from bronchospasm which can be caused by antiasthma drugs, or allergen or the disease

                                                                                                                           i.      BRONCHOSPASM IS CONSIDERED A MEDICAL EMERGENCY, REPORT THIS IMMEDIATELY

                                                                                                                         ii.      Check vitals and response to drug q 5-15 minutes until stabilized

c.       Impaired Oral Mucous Membranes – throat irritation and promote candia infections.  Tell pt to use strict oral hygiene and cleanse the inhaler.

d.      Imbalanced Nutrition – pt with nausea better to eat frequent small meals
PT taking theophylline may have heartburn (relaxes esoph. Sphincter) – help pt to remain upright and sleep with head up

e.       For unpleasant taste, chew gum, candy

1.      Promoting environmental control

a.       Do not go near smoke

b.      If pollen a problem, stay indoors when pollen cout is high

c.       Control dust mites by washing bedding 1 X week in hot water.  Are special dust proof covers

d.      For cold air, wear scarf over mouth and nose

e.       If sxs w/ exercise work with dr to figure out ways to exercise bc it is important to exercise!

f.        If allergic to sulfites, avoid dried fruit, wine, etc

2.      Are Asthma Action Plans in multiple languages online

3.      Pt taught how to use drugs according to their action plan (all aren’t used all the time)

4.      Pt taught how to interpret breathing status and which meds

5.      Pt uses a peak flow meter to monitor breathing status at home, nurse teaches how to use and when to notifyPCP

a.       Explain use of inhalers, do not assume pt knows how to use.  Review instructions with pt, different inhalers are different.  Have pt return demonstration to evaluate proper technique, and review at follow ups.

b.      Take drugs as prescribed even during sx free times (LABAs)

c.       Follow action plan to increase meds, or add another

d.      Check before using herbals withPCP

e.       Check meds often and make sure don’t run out

f.        If  LABA for preventing EIB, give at least 30 before and do not take more for 12 hours

g.       Adrenergic bronchodilators may cause nervousness, insomnia.  ContactPCP if severe.

h.       For xanthine derivatives avoid foods that have xanthine like colas, coffee, chocolate and charcoal preparted foods

i.         For immunomodulators, be aware that an anaphylactic rxs can occur for up to a uear after doing!  ContactPCP if hives, itching, and seek emergency care if trouble breathing.

j.        Bronchospasm is emergency and call 911

k.      Candida infections (above) and oral care (above)

l.         If nauseated (see above)

m.     Unpleasant taste (above)

n.       Do not swallow inhaler meds