Upper Respiratory

• Nose
• Nasal cavity
• Paranasal sinuses
• Pharynx

Lower Respiratory

• Larynx
• Trachea
• Bronchi
• Bronchioles
• Alveoli of the lungs

Goals to suppress COPD

• Smoking cessation
• Tx & prevention of acute exacerbations
• Reduction in rate of progression of disease
• Should receive flu & pneumococcal vaccinations as standard-of-care (esp. for older pts.)

Chronic Obstructive Pulmonary Disease

(COPD)

• Chronic Bronchitis: chronic or recurrent excess mucous production with cough; decrease in oxygen; usually due to infection
• Emphysema: cannot take deep breaths bc of loss of recoil; puffing

Early stages of COPD

• Wheezing at rest & prolonged expiratory phase
• Diminished breath sounds
• Reduced rib cage expansion
• Hyper-resonance of the lungs
• Breathlessness
• Cough (usually productive of sputum)

Advanced stages of COPD

Force Expiratory Volume (FEV1)

• Nonsmokers: FEV1 in nonsmokers without respiratory disease begins an annual decline at age 35; rate of loss is normally 25-35 ml each year.
• Smokers: Annual decline in heavy smokers or susceptible people can be up to 100 ml a year.
• Everyone has a little reserve left

Diagnosis of COPD 

• Spirometry
• Chest radiographs
• Arterial blood gases
• Hallmark of COPD is a decrease in FEV1 in forced vital capacity (FVC) ratio to below 75% on spirometry
• Severity of COPD is usually based on FEV1 findings alone

Drugs used to tx COPD

• Anticholinergics
• Beta2 Agonists
• Methylxanthines
• Glucocorticoids

Anticholinergics 

(used to tx COPD)

Ipatropium, Tiotropium, Atropine

• Maintains effectiveness even after yrs. of use
• Less systemic side effects than that of beta2 agonist
• Slower onset of action than beta agonist
• Do NOT use as PRN, use as schedule dosing
• For chronic COPD use Ipatropium and a short acting beta2 agonist as a rescue inhaler
• Anticholinergics are favored when tx COPD

Beta2 Agonist

(in tx of COPD)

Albuterol, Levalbuterol, Salmeterol

• Albuterol is first choice in emergency situation
• Levalbuterol used for children bc only has R isomer (no tremors associated with Albuterol)
• Salmeterol is NOT quick acting but has longer DOA 

Methylxanthines

(used in tx of COPD)

Theophylline

• Narrow therapeutic index, must monitor other drugs being taken in conjuction

Glucocorticoids

(used in tx of COPD)

• IV: Methylprednisolone, hydrocortisone, cortisone, dexamethasone
• PO: Hydrocortisone, prednisone, methylprednisolone, triamcinolone, dexamethasone
• Inhaled: Triamcinolone, beclomethasone, Flunisolide (remember with steroids ALWAYS wash mouth after use to prevent fungal infection)

MOA of Leukotriene Antagonist

• Block release of leukotrienes in the lungs; decrease inflammation

MOA of Methylxanthines (Theophylline)

• Inhibit breakdown of sensitized mast cells that stimulate release of histamine, serotonin and SRS-A

MOA of Mast Cell Stabilizers

• Inhibit release of histamine from mast cells to reduce allergic effects

MOA of Sympathetic Agonists

• Stimulate sympathetic systems to decrease mucus secretions & relax bronchial muscle spasms

MOA of Corticosteriods

• Produce anti-inflammatory effect & reduce mucus secretions & tissue histamine

MOA of Anticholinergics

• Reverse effects of ANS on pulmonary tree and smooth muscle

Asthma: Exercise Induced Bronchospasm

• Starts immediately after exercise
• Peaks in 5-10 minutes
• Resolves in 20-30 minutes
• Use beta2 agonist immediately before exercise or Cromolyn inhaled 15 min. before exercise to prevent.

Step 1: Mild Intermittent Asthma

• Treated on a PRN basis, no long term meds are needed
• Acute attacks treated with beta2 agonist
• If needed less than twice weekly; nocturnal symptoms less than twice monthly; PEF/FEV are greater than 80% predicted, PEF variability is less than 20% then pt. has mild, intermittent asthma

Step 2: Mild Persistent Asthma

• Long term control with low dose glucocorticoid and continue with short-acting beta2 agonist
• If pt. has symptoms more than twice a week, nocturnal symptoms more than twice a month, PEF/FEV is greater than 80% predicted and PEF variability is 20-30%, pt. has mild persistent asthma

Step 3: Moderate Persistent Asthma

• Inhale medium or low dose glucocorticoid with long-acting inhaled beta2 agonist (Salmeterol) with short-acting beta2 agonist for emergencies.
• Pts. with symptoms daily, nocturnal awakenings at least once a week, PEF/FEV is greater than 80% predicted and PEF variability is greater than 30% have moderate persistent asthma.

Step 4: Severe Persistent Asthma

• High dose inhaled glucocorticoid with long-acting beta2 agonist; if need be an oral glucocorticoid can be added; may try to step down meds once symptoms are controlled.
• If pt. has continuous symptoms, frequent nocturnal awakenings and exacerbations, PEF/FEV less than 60% predicted, PEF variability more than 30%.

Acute Severe Exacerbations

• Hospitalization may be required; if pt. is unconscious or cannot generate PEFR, SQ epinephrine should be given.

Zone System for Monitoring Asthma Tx

(Green Zone, Yellow Zone, Red Zone)

• Green Zone: Pt. has no symptoms and has a PEFR greater than 80% of their personal best, control is good.
• Yellow Zone: Use beta2 agonist, if this does not work use a short course (4 days) of oral glucocorticoid with tapering dose.
• Red Zone: Symptoms occur at rest or interfere with activities and PEFR is less than 50% of personal best. Inhale beta2 agonist immediately, if PEFR remains below 50%, seek medical attention.

Inhalation Devices

1. Metered-dose inhalers (CFCs and HFAs)
2. Dry-powder inhalers
3. Nebulizers

Metered-dose inhalers (MDI)

• Releases a fixed amount of drug with each actuation
• Chlorofluocarbons (CFCs)
• Hydrofluoalkane (HFAs)
• Only 10% reaches the lungs (use spacers esp. with glucocorticoids)

Dry-powder inhalers

• Delivers dry micronized powder directly into the lungs
• No propellant is employed
• Delivers more drug into the lung

Nebulizers

• Coverts drug solution into a mist much finer than produced by inhalers

Drugs used to tx asthma

• Two main classes: anti-inflammatory agents (glucocorticoid & Cromolyn) & bronchodilaters (beta2 agonist)
• Other classes: Methylxanthines, Anticholinergic, Leukotriene modifiers

Glucocorticoids

(General MOA)

• Most effective (inhalation, PO, IV)
• Used on fixed schedule not PRN
• Suppresses inflammation that reduces bronchial activity; decreases synthesis & release of inflammation mediators (leukotrienes, histamine, prostaglandins)
• Use Beta-2 agonist 5 min. BEFORE using a glucocorticoid so it can penetrate deeper in the lungs

Inhaled Glucocorticoids

(Drugs)

1st line tx used in pts. with moderate-severe asthma used daily not PRN.

• Beclomethasone (QVAR, Beconase) HFA
• Budesonide (Pulmicort) Nebulizer and DPI
• Flunisolide (Aerobid)
• Fluticasone (Flovent) HFA
• Mometasone (Asmanex) DPI
• Triamicinolone (Azmacort)

Inhaled Glucocorticoids

(Precautions/Adverse effects)

• Watch for adrenal suppression and bone loss
• Older pts. should do weight bearing exercises
• Watch for pts. with diabetes bc oral glucocorticoids contain sugar

Oral Glucocorticoids

(Drugs and Adverse effects)

• Prednisone, Prednisolone, Fludrocortisone (Florinef)
• Withdraw tx with tapering dose
• Increased risk of PUD (take with food)
• Adverse effects: PUD, hyperglycemia, adrenal suppression

Prednisone

• Decrease inflammation by suppression of migration of leukocytes & reversal of increased capillary permeability
• Taper oral dose if use for longer than 2 weeks (allow adrenal to start working on its own again); take in the morning with food
• Use of NSAIDs may increase GI ulceration

Beta2 Agonist (in tx for asthma)

• Rarely see PO, mostly inhalation
• All oral beta2 agonists are long-acting
• Most inhaled beta2 agonist are short-acting, except Salmeterol & Formoterol
• Increase heart rate (except Levalbuterol), increase blood pressure, increase blood glucose (caution pts. with diabetics)

Nonselective Epinephrine

(General MOA, management)

Bronkaid Mist, Primatene Mist

• Used for bronchial asthma, bronchitis, prevention of bronchospasm
• Routes of administration: Oral inhalation, SQ, IM, Intraspinal, IV, Intracardiac
• Emergency self inject with epinephrine SQ

Isoproterenol

NONSELECTIVE BETA AGONIST

• Bronchial asthma, bronchitis, emphysema
• Caution: arrhythmia, coronary insufficiency, HTN, hyperthyroidism, diabetes

Inhaled Short-Acting Beta2 Agonist

Albuterol (Proventil HFA, Ventolin HFA, ProAir HFA)

Bitolterol (Tornalate)

Levalbuterol (Xopenex nebules, Xopenex HFA)

Pirbuterol (Maxair)

• Effect is almost immediate & can persist for up to 3-5 h; long-acting can persist up to 12 h.
• Taken PRN of for exercise induced asthma
• For severe, acute attack use a nebulizer
• Adverse effects: tremor (sidelined by taking Levalbuterol, esp. in children)

Albuterol

(Drug interactions and nursing management)

• Drug interactions: MOAI, Epinephrine, other inhaled sympathomimetics
• Management: smoking cessation, foul taste will disappear, rinse mouth after inhalation, excessive use can cause reflexive bronchospasm

Inhaled long-acting Beta2 Agonist

Formoterol (Foradil Aerolizer): works within 1-3 min

Salmeterol (Servent Diskus): works within 10-30 min

• Dosing done on fixed schedule, not PRN
• Either PO or inhaled; not given alone but in combo with glucocorticoid, NOT first line of tx

Oral Beta2 Agonist

Albuterol (Proventil, Volmax) 

Terbutaline (Brethine)

• Only used for long term control bc effects are too slow; should not be used alone
• Adverse effects: Will still activate some Beta1 receptors in the heart (caution pts. with heart disease)
• Can cause tremor by stimulating Beta2 rec. in skeletal muscle & will decrease with increased use

Combination of Glucocorticoid/Beta2 Agonist

Fluticasone (glucocorticoid) & Salmeterol (Advair Diskus)

• Approved for maintenance in adults & children at least 12 yrs. old

Cromolyn (Mast Cell Stabilizer)

(General MOA and Contraindications)

NOT BRONCHODILATOR

• Cromolyn (Intal), Nedocromil (Tilade MDI), Nasalcrom 
• MOA: inhibits release of mediators from mast cells including histamine and decrease number of eosinophils; prophylactic use not acute attack (reduces frequency and severity of attacks)
• Contraindications: Do not use in acute attacks, impaired hepatic/renal fx

Anticholinergics

(Drugs & MOA)

Ipratropium (Atrovent HFA, Combivent & DuoNeb)

Tiotropium (Spiriva): long-acting

• Blockade of muscarinic receptors in bronchi, causing bronchodilation (ACh antagonist)

Ipatropium Bromide

(Adverse effects & Contraindications)

• Adverse effects: Cough, nervousness, dry mouth, hoarseness
• Contraindications: hypersensitivity to atropine and peanuts, glaucoma, bladder neck obstruction

Methylxanthines

(Drugs and MOA)

Theophylline (Theo-24, Uniphyl)

Aminophylline (Truphylline)

• Used to tx asthma, chronic bronchitis, emphysema
• Has narrow therapeutic index
• Given PO, NO effect by inhalation

Theophylline

(Pharmacokinetics, adverse effects, inc. therapeutic effect & dec. therapeutic effect)

• Pharmacokinetics: onset within 30-60 min., half-life adults 8 h & pedi 4h, DOA 24 h, hepatically metabolized to caffeine and excreted by kidneys
• Adverse effects: Life threatening: respiratory arrest, ventricular tachycardia & common: tachypnea, palpitations, sinus tachycardia, nervousness, restlessness, insomnia, anorexia
• Increases ther. effect: age, erythromycin, cimetidine, ciprofloxacin, disease: cirrhosis, pulmonary edema, congestive heart failure, severe COPD
• Decreases ther. effect: adolescence, phenobarbital, phenytoin, tobacco, marijuana, high protein diet

Theophylline

(Contraindications, nursing management & overdose)

• Contraindications: hypersensitivity, PUD, CV disease, seizure disorder
• Management: increase fluid intake to decrease secretion viscosity, smoking cessation, check serum drug levels for 6-12 mo if asymptomatic
• Overdose: no known antidote; decrease drug absorption and give activated charcoal or gastric lavage

Leukotriene Modifiers

(Drugs & General MOA)

Suppress effects of leukotriene and decreases bronchoconstriction, inflammation, edema, mucus secretion & recruitment of eosinophils.

• Zileuton (Zyflo): rarely see; blocks leukotriene synthesis
• Zafirlukast (Accolate): Anti-inflammatory leukotriene receptor antagonist which decreases bronchoconstriction; food reduces absorption (give on empty stomach), hepatic metabolism (check LFTs and ALT); inhibits cytochrome p450 (Theophylline won't be metabolized if also on Accolate)
• Montelukast (Singulair):  used the most; tabs, chewable, granules; same MOA as Accolate; approved pts. over 1 yr. age; protein bound and metabolized by CYTP450; less effective than inhaled glucocort.; no liver damage w/ no serious drug interactions (does not inc. levels of warfarin or theophylline)

Tuberculosis

(Overview of infection & skin test)

• Caused by Mycobacterium tuberculosis & may have no symptoms
• Unless receive proper medication, can harbor lifelong infection
• Tx is divided into 2 phases and is long so adherence is a problem: 1st induction phase which renders sputum non-infectious; 2nd phase tx with 4 drugs 1-3/wk
• Intradermal injection of Purified Protein Derivative (PPD)
• If pt. exposed to tuberculosis, the immune system elicits a response in 48-72 h; the smaller the size the more aggressive the tx
• 2 or more drugs are used to kill active/resting tubercle bacilli

Tuberculosis Tx

(Regimens, 1st line drugs & guidelines)

• Monitor closely for compliance
• Chemoprophylaxis (prevent pt. on chemo from getting contracting TB)
• 1st line drugs: Isoniazid (INH), Rifampin, Pyrazinamine (PZA), Ethambutol or Streptomycin
• Guidelines: usually prolonged tx necessary

Isoniazid

(General MOA)

PREFERRED TX FOR LATENT & PREVENTIVE TB

• Highly selective for M. tuberculosis
• Tx given over 6-9 mo. (given daily or twice weekly)
• PO or IM
• Take on empty stomach
• Hepatically metabolized & excreted by kidneys

Isoniazid

(Adverse effects and drug interactions)

• Adverse effects: depletes Pyridoxine (B6); hepatoxicity (monitor AST and ALT monthly)
• Drug interactions: ETOH decrease metabolism which increases risk of hepatoxicity (avoid alcohol: cause severe hangover); antacids decrease metabolism; Disulfiram (Antabuse)

Rifampin

(General MOA and adverse effects) 

1st LINE TX FOR TUBERCULOSIS

• MOA: Broad spectrum antibiotic agent against TB and N. meningitis; half-life 5 h; hepatically metabolized; excreted in feces
• Adverse effects: Anorexia, mouth/tongue soreness, chills, respiratory difficulty, shivers, fever, bone/muscle pain

Pyrazinamide

(Adverse effects)

1st LINE TX FOR TUBERCULOSIS

• Urination difficulties, pruritus (itch), rash, photosensitivity, jaundice, joint pain & swelling

Ethambutol

(MOA and adverse effects)

1st LINE TX FOR TUBERCULOSIS

• MOA: Effective ONLY against actively dividing mycobacterium; take with food
• Adverse effects: Optic neuritis (blurred vision, loss of red-green perception) and renal impairment

Rifampin

(Drug interactions and nursing management)

• Drug interactions: ETOH increases risk of hepatoxicity risk, decreases effectiveness of corticosteroids; HIV protease inhibitors
• Management: Baseline & periodic hepatic fx; give with 240 ml water on empty stomach; use alternate form of contraception (decreases effectiveness of birth control); avoid alcohol

Streptomycin

2nd LINE TX FOR TUBERCULOSIS

• Aminoglycoside
• Adverse effects: Tinnitus, Nephrotoxicity, Hepatoxicity

Tuberculosis Management

• Give INH, ethambutol, rifampin single OBSERVED dose daily
• Give Rifampin 1 h before or 2 h after meal
• Streptomycin deep IM, rotate sites
• Report severe GI problems, yellow sclera, dark urine, clay-colored stool, vision, hearing changes, numbness or tingling

Expectorants

GUAIFENESIN

• MOA: Irritates gastric mucosa & stimulates respiratory tract secretions; take with a lot of water (water acts as surfactant); beware of sugar and ETOH content

Decongestants

• Pseudoephedrine & Phenylephrine
• Caution pts. with HTN

Cough Suppressants

• Dextromethorphan, Codeine, Benzonatate
• Suppresses cough, watch for ETOH and sugar content

Antihistamines

• Loratidine
• Certirizine
• Fexofenadine
• Diphenhydramine
• Chlorpheneramine

2nd Line Tx for Tuberculosis

• Streptomycin
• Para-aminosalcylic acid
• Kanamycin
• Amikacin
• Capreomycin
• Ethionamide
• Cycloserine
• Levofloxacin, Moxifloxacin & Gatifloxacin