DRUGS ACTING ON THE RESPIRATORY SYSTEM

Upper Respiratory Tract Conditions

Common cold
viral infection URT
release of H2,prostaglandins leads to inflammatory response
Seasonal rhinitis
inflammation of nasal cavity
commonly called as allergic rhinitis or hay fever,
caused by reaction to specific antigen
Sinusitis
inflammation of epithelial lining of sinus cavity
Pharyngitis & Laryngitis
infection of pharynx & larynx
Commonly caused by bacteria and viruses
Frequently seen with influenza
Lower Respiratory Tract Conditions
Pneumonia:
inflammation of lungs
bacterial, viral, aspiration
Atelectasis
lung collapse as a result of outside pressure against alveoli
eg.
Pneumothorax,
Pleural effusion or
Tumors
Bronchitis: Acute/ Chronic
inflammation of bronchi causing an obstructed or narrowed airflow
Bronchiectasis:
Dilation of bronchial tree, chronic inflammation of bronchial passages, leads to fibrous scar tissues in
bronchia
Obstructive Pulmonary Diseases
Obstruct major airways
COPD (emphysema, asthma, chronic bronchitis)
Obstruct alveoli
RDS
Asthma
recurrent reversible bronchospasm, inflammation, hyperactive airways
leading to narrowed or obstructed airways
Chronic Obstructive Pulmonary Disease (COPD)
permanent, chronic obstruction of airways
destruction of respiratory defense mechanisms, physical structure
resulting to:
Airflow obstruction on inspiration
Over inflated lungs
Poor gas exchange

Causes :
Emphysema (pink puffers) & chronic bronchitis (blue bloaters)
Cystic Fibrosis
Hereditary disease
accumulation of copious amounts of very thick secretions in lungs
Respiratory Distress Syndrome
found in premature neonates
fully developed lungs, low surfactant to maintain open airways to allow for respiration
Obstruct alveoli
DRUGS ACTING ON THE UPPER RESPIRATORY TRACT
Definitions
Antitussive
block cough reflex
Decongestants
decrease overproduction of secretions eg. nasal, oral, nasal steroid
Antihistamines
block release or action of H2( up secretions, narrows airways)
Expectorants
up productive cough to clear airways
Rebound Vasodilation/ Congestion
nasal passages become congested as drug effect wears off
rhinitis medicamentosa
2ndary to frequent / prolonged use of decongestants

Non pharmacologic Nursing Measures on the Mgt of URT problems

Encourage up fluid intake, good nutritional intake
Cool temperatures, use of topical lozenges
Avoid contact with known allergens or irritants, smoke filled areas
Use of air humidifier , air purifier
Observe hand hygiene as mandated by CDC, WHO
Proper hygiene and sanitation
Cover mouth, nose when sneezing & coughing
Provide adequate rest, sleep
Monitor OTC usage to prevent overdose

Antitussives
Two Classifications
Central Acting:
Acts medullary cough center in brain
Examples :
Codeine (Hycodan),
Dextromethorphan
not associated with CNS depression , addiction at usual dosage
Local acting:
Direct effect on respiratory tract
Block effectiveness of stretch receptors that stimulates cough reflex; local anesth on resp
Example:
Benzonatate (Tessalon perles)
Adverse Effects
Central Acting:
Drying Effect on mucous membranes
CNS depression
GI s/s
CV depression
Local Acting:
GI s/s
headache, feeling of congestion, dizziness,
Chills, chest numbness
Cautions & Contraindications
Asthma ,emphysema= need to cough to maintain airways
Hypersensitivity or Hx narcotic addiction
HI or CNS affectations
Pregnancy, lactation
Nursing Care :
Assessment on need for med use
Drug should not be taken longer than recommended
Provide non pharmacologic measures
Perform deep breathing & coughing exercises, CPT
Increase hydration
Advise not to take other OTC med
If symptoms persists, consult the doctor

Decongestants
Adrenergics or Sympathomimetics that leads to local vasoconstriction
block effects of inflammation on nasal mucous membranes
Blocks s/s of inflammation ( swelling, congestion, increased secretions)
Kinds:
Topical nasal decongestants
Oral decongestants
Topical nasal steroid decongestants
Used to relieve nasal congestion (common colds, sinusitis, allergic rhinitis)
Used in dilation of nares to facilitate medical examination
Used to relieve pain, congestion of otitis media
direct local effect
Common Drugs:
Beclomethasone (Beclovent)
Budesonide (Rhinocort, Budecort)
Flunisolide (AeroBid)
Flucatisone ( Flonase, Nasonex, Flovent)
Ephedrine nasal
Oxymetazoline (Drixine, Afrin)
Phenylephrine(Neo-Synephrine)
Tetrahydrozoline (TyZine )
Cautions and Contraindications:
Mucous membrane lesion/ erosions
Glaucoma, DM, CAD, prostate probs
Adverse Effects:
rebound congestion (rhinitis medicamentosa)
sympathomimetic effect
Note:
Results are not seen immediately(2-3 wks)
Assess for signs of infection/ fungal
Oral Decongestants
Stimulates adrenergic receptors in nasal mucous membrane
Decrease nasal congestion ( common cold, sinusitis, allergic rhinitis)
Example :
Pseudoephedrine (Sudafed)
Adverse effects:
rebound congestion
sympathetic effects

Antihistamine
Block H2 receptor sites
Effects:
Relieves resp s/s
Anticholinergic effect
Antipruritic effect
Indications:
Seasonal allergic rhinitis
Allergic conjunctivitis
Uncomplicated urticaria
KINDS:
First Generation
greater anticholinergic effects, with resultant drowsiness
Cetirizine ( Virlix)
Chlorpheniramine( Chlor-Trimeton)
Diphenhydramine ( Benadryl)
Hydroxyzine (Iterax)
Promethazine (Phenergan)
Second Generation
fewer anticholinergic effects, less sedating
Desloratidine (Clarinex)
Fexofenadine (Allegra)
Loratidine (Claritin)
Cautions and Contraindications:
Pregnancy and lactation
Renal or hepatic impairment
History of Arrhythmias
Interactions:
MAOI = prolonged anticholinergic effects
Ketoconazole/ Erythromycin + Fexofenadine(Allegra) = increased fexofenadine levels
Adverse Effects:
CNS effects
Drying effects of Resp , GI mucous membranes
GI s/s
Nursing Care: Antihistamine
Administer drugs on an empty stomach, with meals if with GI upset
Fall and safety precautions
Increase hydration
Offer sugarless lozenges, candies
Avoid alcohol consumption
Avoid activities that requires alertness

Expectorants
Examples :
Guaifenesin (Bisolvon, Myracof, Robitussin)
Adverse Effects:
GI s/s,
Headache,
dizziness
Nursing care:
Not to use drug for more than 1 week
Give small frequent meals
Increase oral fluid intake
Avoid activities that require mental alertness
Caution the patient about the use of OTC drugs
Health teaching: deep breathing, coughing exercises, CPT

Mucolytics
Breakdown mucous in resp tract
given via nebulization or by direct instillation via ET, trach tube
Indications:
patients with difficulty mobilizing ,
coughing up secretions
Bronchitis
Atelectasis caused by mucous obstruction
Medications:
Acetylcysteine
Mucomyst ( via neb, Direct instill)
antidote in acetaminophen toxicity
Has a rotten egg like odor, after-taste (neb)
Liquefy secretions
Liquefy in 50-100 ml H20 (effervescent tabs Fluimucil)
Dornase alfa ( Pulmozyme) via nebulizer
Relieve secretion build up (cystic fibrosis)
Fluimucil (effervescent)
Cautions and Contraindication
Acute bronchospasm, PUD
esophageal varices
Adverse effects:
GI s/s , rash

Nursing considerations : Mucolytics

Caution : asthma,resp insuff, elderly,debilitated patients
If given via neb:
o Use face mask not via handbulb
o Cough to clear airway before giving
Store in refrigerator post opening, use within 96 hrs
Tx acetaminophen toxicity: (within 24hrs)
o Oral=dilute with cola, juice, H20
o Incompatible : tetracycline,H202,ampicillin ( 2 hrs apart)

DRUGS USED TO TREAT OBSTRUCTIVE PULMONARY DISORDERS

Bronchodilators/ Anti asthmatics
facilitate respirations by dilating airways
Uses :
bronchial asthma
Bronchospasms associated with COPD
KINDS:
Xanthines
Sympathomimetics
Anticholinergics bronchodilators
Inhaled Steroids
Leukotriene receptor Antagonist
Mast Cell Stabilizers
Lung surfactants
Xanthines
direct effect on smooth muscles of respiratory tract (bronchi, blood vessels)
inhibits release of slow reacting substances of anaphylaxis, H2
Indications:
asthma
bronchospasm with COPD
patients with Cheyne-stokes respiration=stimulate resp
Tx of Apnea, bradycardia on premature infants
Common Drugs:
Caffeine (Caffedrine)
Theophylline (Theodur,Slo bid)
Aminophyline (Truphylline) IV
Doxophylline (Ansimar)
Interactions:
Nicotine and marijuana= increased metabolism, excretion of Xanthines
Rifampicin, phenobarbital, phenytoin = increased drug metabolism = increased dosage is
needed

Cautions:
CAD, respiratory dysfunction
renal or hepatic disease, alcoholism
Hyperthyroidism
Adverse effects:
SNS like effects
GI s/s,
CNS effects,
CV effects
Therapeutic theophylline level is 10-20 mcg/ml- with narrow margin of safety
>20-25 mcg/ml GI s/s, CNS s/s
>30-35 mcg/ml hyperglycemia, hypotension, arrhythmia, tachycardia, seizures, brain
damage, death
Nursing Care: Xanthines
Proper Administration
Administer Oral Drug with food or milk
Administer PO medications RTC
Use infusion pumps if use IV
Monitor patients response
Blood therapeutic level 10-20 mcg/mL
Relief of s/s
Provide comfort measures:
Adequate rest periods,quiet environment
Diet : control caffeine
Pain mgt for headache as ordered
Health teachings
Monitor blood level result
Extreme caution: if patient decides to decrease or discontinue smoking while on med
Withdrawal s/s

Sympathomimetics
Non selective alpha & beta2 adrenergic agonist
Adverse Effects:
SNS effects
Beta selective Adrenergic agonist
Isoproterenol (Isuprel)
Selective - beta2 adrenergic agonist
Short Acting
Levalbuterol (Xopenex),
Albuterol (Proventil),
Terbutaline (Bricanyl),
Salbutamol (Ventolin)
Long Acting
Salmeterol (Serevent)
=tx for bronchospasm associated with chronic asthma and COPD
Cautions:
CV disease, arrhythmias, DM, HTN
Examples of Metered-Dose Inhalers and Spacers
Anticholinergic Bronchodilator
antagonizing ACh action at receptor sites, leads to bronchodilation
Once-daily Maintenance
tx in COPD, bronchospasm , emphysema
Common Drugs:
Ipratropium (Atrovent) onset 15 mins
Tiotropium (Spiriva) rapid onset, long duration
Spiriva (tiotropium)
Cautions:
Narrow angle glaucoma
Bladder neck obstruction, BPH
Adverse Effects:
SNS effects
dizziness,
headache,
fatigue,
nervousness
dry mouth,
sore throat,
palpitations and
urinary retention

Nursing Responsibilities: Anticholinergic Bronchodilator

Provide Comfort Measures:
Encourage to void before each dose
Prevention of Dry mouth: Sugarless lozenges
Provide small frequent meals
Fall and safety precautions
Health Teachings
Not intended for acute attacks
Adequate hydration
Review use of inhaler not to exceed 12 inhalations in 24 hours
Review use of Sprays not to exceed 8 sprays per nostril in 24 hours
Allow 2 minute interval for every dose
Give the drug on time

Inhaled Steroids
Increases airflow, facilitates respiration
decreases numerous systemic effects that are associated with oral steroid use
Therapeutic/effective levels: achieve within 2-3 weeks
Effects:
Decreased swelling
Beta adrenergic agonist
Indications:
Asthma= prevention and tx
Treat chronic steroid dependent bronchial asthma
Adjunct for those not responding to traditional bronchodilators
Common Drugs:
Beclomethasone (Beclovent)
Budesonide (Pulmocort,Budecort)
Flunisolide (AeroBid)
Fluticasone (Flovent, Flonase, Nasonex)
Triamcinolone (Azmacort)
Cautions:
Not for emergency use , not for acute asthmatic attacks or status asthmaticus
Pregnancy and Lactation
Infections
Adverse Effects:
SNS effects
Sore throat,
hoarseness,
coughing,
dry mouth
Pharyngeal, laryngeal fungal infections

Nursing Care :
Proper Administration:
Do not administer to treat acute asthmatic attacks/status asthmaticus
Taper systemic oral steroids carefully during the transfer to inhaled steroids
Use decongestant drops before using the inhaled steroids
Monitor patients
for s/s Infections
Comfort measures
Gargle after using inhaler
Fixed combination resp drugs
Advair diskus/ Seretide diskus
Fluticasone + salmeterol
Tx asthma: 4yrs and older
Combivent
Ipratropium ( anticholinergic) + albuterol

Leukotriene Receptor Antagonists

antagonize receptors for production of leukotrienes( D4, E4)
which blocks asthma s/s
Indications:
Prophylaxis, chronic treatment of asthma in adults and younger than 12 yrs
Common Drugs:
Montelukast (Singulair)
Zafirlukast (Accolate)
Zileuton (Zyflo)= use in 12 yrs below
Cautions:
hepatic,renal impairments
Interactions:
Propranolol, Theophylline,warfarin, Ca channel blocker and ASA = increased toxicity
Adverse effects:
GI s/s;
increase liver enzymes
Flu like s/s
Nursing Care:
Administer on an empty stomach 1 hr before or 2 hrs after meals
Do not administer during acute asthma attacks or bronchospasm
Take the drug continuously, do not stop during symptom free periods
Fall and safety precautions
Avoid use of OTC meds with ASA (decreased above drug affect)

Mast Cell Stabilizer

Block inflammation mediators, decrease airway swelling & blockage
Common Drugs:
Cromolyn (Intal)
Tx chronic asthma, allergic rhinitis
Not to be used on Acute asthmatic attacks, below 2 yrs
Adverse effects: GI s/s, dry mouth
Nedocromil (Tilade)
Mild to mod asthma
Not use below 12 yrs
Adverse effects: + lacrimation

Nursing Care: Mast Cell Stabilizer

Avoid discontinuing drug abruptly taper dosage
Continue taking drug even if symptom free
Administer 30 min before meals and at bed time
Safety and fall precautions
Avoid wearing soft contact lens
Cromolyn (Intal) stains contact lens

Lung Surfactants
replace surfactant missing neonates lungs with RDS
Instill via trachea
Indications:
rescue treatment of infants with RDS
prophylactic treatment of high risk RDS infants( low birth wt)
Common Drugs:
Beractant (Survanta)
Calfactant (Infasurf)
Colfosceril (Exosurf)
Poractant (Curosurf)
Adverse Effects:
intraventricular hemorrhage,
pneumothorax,
pulmonary air leak,
Hyperbilirubinemia, sepsis
Nursing Care:
Monitor patient continuously during administration
Crash cast stand by
Ensure proper placement of the ET with bilateral chest movement
Suction infant immediately before drug administration but do not suction for 2 hrs after administration
Provide support, encouragement to parents of patient
Continue other mgt related to patients immaturity

Developed by: Richmond M. Rivera

Prepared by: Mrs. Genecar Pe Benito, RN, MAN, CRRN
University of Santo Tomas-College of Nursing