DRUGS ACTING ON UPPER REPIRATORY TRACT The 

RIGHT LUNG is divided into three LOBES, or sections.

The SINUSES are hollow spaces in the bones of your head. The left lung is divided into two LOBES.
Small openings connect them to the nasal cavity. The sinuses
help to regulate the temperature and humidity of the air you The PLEURA are the two membranes that surround each lobe
breathe in, as well as to lighten the bone structure of the head of your lungs and separate the lungs from your chest wall.
and to give tone to your voice. The bronchial tubes are lined with CILIA (like very small hairs)
The NASAL CAVITY (nose) is the best entrance for outside air that have a wave-like motion. This motion
into your respiratory system. The hairs that line the inside wall carries MUCUS (sticky phlegm or liquid) upward and out into
are part of the air-cleansing system. the throat, where it is either coughed up or swallowed. The
mucus catches and holds much of the dust, germs, and other
Air can also enter through your ORAL CAVITY (mouth), unwanted matter that has invaded your lungs. Your lungs get
especially if you have a mouth-breathing habit or your nasal rid of the mucus through coughing.
passages may be temporarily blocked.
The DIAPHRAGM is the strong wall of muscle that separates
The ADENOIDS are overgrown lymph tissues at the top of the your chest cavity from your abdominal cavity. By moving
throat. When your adenoids interfere with your breathing, they downward, it creates suction to draw in air and expand the
are sometimes removed. The lymph system, consisting of lungs.
nodes (knots of cells) and connecting vessels, carries fluid
throughout the body. This system helps your body resist The smallest sections of the bronchi are
infection by filtering out foreign matter, including germs, and called BRONCHIOLES, at the ends of which are the alveoli
producing cells (lymphocytes) to fight them. (plural of alveolus).

The TONSILS are lymph nodes in the wall of your pharynx. The ALVEOLI are the very small air sacs that are the
Tonsils are not an important part of the germ-fighting system of destination of air that you breathe in.
the body. If they become infected, they are sometimes The CAPILLARIES are blood vessels that are imbedded in the
removed. walls of the alveoli. Blood passes through the capillaries,
The PHARYNX (throat) collects incoming air from your nose brought to them by the PULMONARY ARTERY and taken
and passes it downward to your trachea (windpipe). away by the PULMONARY VEIN. While in the capillaries, the
blood moves carbon dioxide into the alveoli and takes up
The EPIGLOTTIS is a flap of tissue that guards the entrance to oxygen from the air in the alveoli.
your trachea. It closes when anything is swallowed that should
go into the esophagus and stomach. What are the common respiratory diseases?

The LARYNX (voice box) contains your vocal cords. When  Common Colds

moving air is breathed in and out, it creates voice sounds.  Rhinitis
 Sinusitis
The ESOPHAGUS is the passage leading from your mouth  Pharyngitis
and throat to your stomach.
 Tonsillitis
The TRACHEA (windpipe) is the passage leading from your  Bronchiectasis
pharynx to the lungs.  Asthma
 Pneumonia
The RIBS are bones supporting and protecting your chest  Cystic Fibrosis
cavity. They move a small amount and help the lungs to  COPD
expand and contract.
 RDS
The trachea divides into the two main BRONCHI (tubes), one
for each lung. The bronchi, in turn, subdivide further into
bronchioles.
COLDS Pharyngitis

Rhinovirus common viral infectious agent in humans and is the It is a sudden painful inflammation of the pharynx, the back
predominant cause of the common cold and virus portion of the throat that includes the posterior third of the
tongue, soft palate, and tonsils.
Coronavirus
Sudden sore throat
RSV (Respiratory syncytial virus) and parainfluenzaInfluenza,
commonly known as "the flu", is an infectious disease caused Mostly viral
by an influenza virus. Symptoms can be mild to severe. The
most common symptoms include: high fever, runny nose, sore Risk factors for chronic:
throat, muscle and joint pain, headache, coughing, and feeling Habitual use of tobacco, alcohol
tired.
Tonsillitis
These viruses invade the tissues of the upper respiratory tract,
initiating the release of histamine and prostaglandins and Infection of the adenoids frequently accompanies acute
causing an inflammatory response. tonsillitis. The most common viral pathogen is Epstein–Barr
virus, although cytomegalovirus may also cause tonsillitis and
As a result of the inflammatory response, the mucous adenoiditis. For tonsillitis (viruses for young children)
membranes become engorged with blood, the tissues swell, Streptococcus pyogenes for bacterial
and the goblet cells increase the production of mucus.
Bronchiectasis
These effects cause the person with a common cold to
complain of sinus pain, nasal congestion, runny nose,  A condition where the bronchial tubes of your lungs
sneezing, watery eyes, scratchy throat, and headache. are permanently damaged, widened, and thickened.
These damaged air passages allow bacteria and
mucus to build up and pool in your lungs. This results
RHINTIS: Rhinitis is inflammation and swelling of the nasal in frequent infections and blockages of the airways.
mucosa  Dilation and destruction of larger bronchi caused by
chronic infection and inflammation
Exposure to allergen that causes the allergic response;
Release chemicals called histamine which cause vasodilation Cystic fibrosis common cause
and increase capillary permeability to a specific antigen (e.g.,
Chronic cough, purulent sputum, dyspnea, crackles ronchi and
pollen, mold, dust) with a vigorous inflammatory response,
wheezing, low grade fever
resulting again in nasal congestion, sneezing, stuffiness, and
watery eyes. Asthma
Corticosteroids and oral or intranasal antihistamines, use of Asthma is a condition in which your airways narrow and swell
saline nasal spray, leukotriene modifiers and may produce extra mucus. This can make breathing
difficult and trigger coughing, a whistling sound (wheezing)
SINUSITIS
when you breathe out and shortness of breath.
The sinuses lighten the skull or improve our voices, but their
main function is to produce mucus that moisturizes the inside  Allergic reaction in the airways result in an immediate
of the nose. This mucus layer protects the nose from reaction with obstruction
pollutants, micro-organisms, dust and dirt.  Release of histamine leads to a Broncho constrictive
process, bronchospasm, and obstruction
Inflammation of the mucus membranes of one of the sinuses
(maxillary or frontal) Pneumonia
Typically ends up an infection because swelling of the mucosa Pneumonia is an infection that inflames the air sacs in one or
thereby blocking the drainage both lungs. The air sacs may fill with fluid or pus (purulent
material), causing cough with phlegm or pus, fever, chills, and
difficulty breathing. A variety of organisms, including bacteria, Patients with asthma and emphysema
viruses and fungi, can cause pneumonia are contraindicated because cough suppression could lead to
accumulation of secretions and a loss of respiratory reserve
Cystic fibrosis
 Emphysema is a lung condition that causes shortness
It is a hereditary disease that affects the lungs and digestive of breath. In people with emphysema, the air sacs in
system. The body produces thick and sticky mucus that can the lungs (alveoli) are damaged. Over time, the inner
clog the lungs and obstruct the pancreas. walls of the air sacs weaken and rupture — creating
Copd larger air spaces instead of many small ones.

Chronic obstructive pulmonary disease, commonly referred to Precaution:

as COPD, is a group of progressive lung diseases. The most Dextromethorphan should not be used with monoamine
common are emphysema and chronic bronchitis. Many people oxidase (MAO) inhibitors; hypotension, fever, nausea,
with COPD have both of these conditions. myoclonic jerks, and coma could occur.
Emphysema slowly destroys air sacs in your lungs, which Mao inhibitors are drugs to treat depression
interferes with outward air flow. Bronchitis causes
inflammation and narrowing of the bronchial tubes , which Myoclonic twitches or jerks usually are caused by sudden
allows mucus to build up. muscle contractions (tightening), called positive myoclonus, or
by muscle relaxation, called negative myoclonus.
Respiratory Distress syndrome
KEY POINTS
Acute respiratory distress syndrome (ARDS) is a severe lung
condition. It occurs when fluid fills up the air sacs in your lungs.  Suppress the cough reflex by acting centrally to
Too much fluid in your lungs can lower the amount of oxygen suppress the medullary cough center or locally as an
or increase the amount of carbon dioxide in your bloodstream anesthetic or to increase secretion and buffer
irritation.
Newborns – preterm
 Cause CNS depression, including drowsiness and
Neonatal RDS occurs in infants whose lungs have not yet fully sedation.
developed. The disease is mainly caused by a lack of a  It should be used with caution in any situation in
slippery substance in the lungs called surfactant. This which coughing could be important for clearing the
substance helps the lungs fill with air and keeps the air sacs airways.
from deflating. Surfactant is present when the lungs are fully  Provide other measures to help relieve cough (e.g.,
developed. humidity, cool temperatures, fluids, use of topical
lozenges) as appropriate

Central nervous system depression is a physiological state

that can result in a decreased rate of breathing , decreased
heart rate, and loss of consciousness possibly leading to
coma or death. It is the result of inhibited or suppressed brain
activity

Take meds for 5 days

Assess respirations and adventitious sounds to assess drug

effectiveness and to monitor for accumulation of secretions
Antitussives are medicines that suppress coughing, also
known as cough suppressants.   Evaluate orientation and affect to monitor for central
nervous system (CNS) effects of the drug.

Decongestants are a type of medicine that can provide short-

Antitussives term relief for a blocked or stuffy nose (nasal congestion).
  They can help ease the symptoms of conditions such nose and promoting drainage of secretions and improved
as colds and flu, hay fever and other allergic airflow now. Yun nga lang, a person can experience rebound
reactions, catarrh and sinusitis. congestion, technically called rhinitis medicamentosa. The
 When allergies make your nose stuffed up, reflex reaction to vasoconstriction is a rebound vasodilation,
an antihistamine generally doesn't help. But a which often leads to prolonged overuse of decongestants.
decongestant might.
Adrenergic - adrenergic activity by stimulating the α1-
 Here's how decongestants work: Allergies make the
adrenergic receptor since they mediate vasoconstriction and
lining of your nose swell. Decongestants shrink
constricting nasal vasculature causes decongestion of nasal
swollen blood vessels and tissues. That relieves the
mucosa.
congestion. But decongestants can’t help
with sneezing or itching. Topical decongestants are sympathomimetic, meaning that
they imitate the effects of the sympathetic nervous system to
Decongestants
cause vasoconstriction, leading to decreased edema and
 Decrease the overproduction of secretions by causing inflammation of the nasal membranes.
local vasoconstriction to the upper respiratory tract;
Sympathomimetic effects (e.g., increased pulse and blood
adrenergic, sympathomimetic
pressure; urinary retention) should be monitored because
 Type of medicine that can provide short-term relief for
some systemic absorption may occur, although these effects
a blocked or stuffy nose (nasal congestion).
are less likely with topical administration than with other routes.
 They can help ease the symptoms of conditions such
as colds and flu, hay fever and other allergic Topical Nasal: check firs nares (nasal spray)
reactions, catarrh and sinusitis.
Topical / nasal Contraindications and Cautions Caution should
Topical be used when there is any lesion or erosion in the mucous
membranes that could lead to systemic absorption. Caution
 With caution to presence of lesion should also be used in patients with any condition that might
 Stinging and burning be exacerbated by sympathetic activity, such as glaucoma,
Oral hypertension, diabetes, thyroid disease, coronary disease, or
 adrenergic properties prostate problems, because these agents have adrenergic
 Well absorbed and reaches peak levels quickly—in properties. Because there are no studies regarding the effects
20 to 45 minutes. of these topical drugs in pregnancy or lactation, if used during
 rebound congestion
pregnancy or lactation, caution is advised
 Feelings of anxiety, tenseness, restlessness, tremors,
hypertension, arrhythmias, sweating, and pallor. Rebound Congestion: constant nasal stuffiness (congestion)
that develops from the overuse of nasal sprays (or drops or
Topical Nasal steroid
gels) that contain a decongestant medicine. If the sensation
May require 1 week peak of onset does not pass, the drug should be discontinued because it
may indicate lesions or erosion of the mucous membranes.
Contraindicated:
Use for longer than 3 to 5 days can lead to rebound
It is the presence of acute infections, TB, local burning, congestion. (Rebound congestion occurs when the nasal
irritation, stinging, dryness of the mucosa, and headache. passages become congested as the drug effect wears of)

Oxymetazoline HCl is a decongestant that shrinks blood Epidrine: Relieves discomfort of nasal congestion associated
vessels in the nasal passages. Dilated blood vessels can with the common cold, sinusitis, allergic rhinitis; relieves
cause nasal congestion (stuffy nose). Oxymetazoline nasal (for pressure of otitis media
the nose) is for temporary relief of nasal congestion (stuffy
nose) caused by allergies or the common cold An adverse effect that accompanies frequent or prolonged use
of these drugs is rebound congestion, technically called rhinitis
Actions; This vasoconstriction leads to a shrinking of swollen medicamentosa.
mucous membranes and tends to open clogged nasal
passages, providing relief from the discomfort of a blocked
Adverse Effects: Disorientation, confusion, light-headedness,  Assess skin color and temperature to assess
nausea, vomiting, fever, dyspnea, rebound congestion. sympathetic response.

 Assess for possible contraindications or cautions: any

history of allergy to the drug or a component of the
drug vehicle; glaucoma, hypertension, diabetes, Antihistamine They're usually divided into 2 main groups:
thyroid disease, coronary disease, and prostate Antihistamines that make you feel sleepy – such
problems as chlorphenamine (including Piriton), hydroxyzine
 Monitor pulse, blood pressure, and cardiac and promethazine
auscultation
 Caution the patient not to use the drug for longer than Non-drowsy antihistamines that is less likely to make you feel
5 days sleepy – such as cetirizine, fexofenadine and loratadine
 safety measures if dizziness or sedation occurs
Antihistamines
 other measures to help relieve the discomfort of
congestion Block the effects of histamine at the histamine-1 receptor sites,
decreasing the allergic response, anticholinergic (atropine-like)
Provide safety measures if dizziness or sedation occurs as a
and antipruritic effects
result of drug therapy to prevent patient injury.
 Indicated for rhinitis, allergic reactions,
■ Institute other measures to help relieve the discomfort of
congestion (e.g., use of a humidifi er, increased fl uid intake,  An onset of action ranging from 1 to 3 hours.
cool environment, avoidance of smoke-fi lled areas) as Exposure to allergen that causes the allergic response;
appropriate. Release chemicals called histamine which cause vasodilation
■ Provide thorough patient teaching, including the drug name and increase capillary permeability to a specific antigen (e.g.,
and prescribed dosage, measures to help avoid adverse pollen, mold, dust) with a vigorous inflammatory response,
effects, warning signs that may indicate problems, and the resulting again in nasal congestion, sneezing, stuffiness, and
need for periodic monitoring and evaluation, to enhance watery eyes.
patient knowledge about drug therapy and to promote Anticholinergic effects: Typical symptoms include dry mouth,
compliance. constipation, urinary retention, bowel obstruction, dilated
Decongestants offer support and encouragement to help the pupils, blurred vision, increased heart rate, and decreased
patient cope with the disease and the drug regimen. sweating 

Summary: Administer drug on an empty stomach, 1 hour before or 2

hours after meals, to increase the absorption of the drug; the
Decongestants cause local vasoconstriction, thereby reducing drug may be given with meals if GI upset is a problem
blood flow on to the mucous membranes of the nasal
passages and sinus cavities. Drowsiness: Caution the patient to avoid alcohol while taking
these drugs because serious sedation can occur.
Rebound vasodilation (rhinitis medicamentosa) is an adverse
effect of excessive or long-term decongestant use.  Dry mouth: Because of the drying nature of
antihistamines, patients often experience dry mouth,
Topical nasal decongestants are preferred for patients who which may lead to nausea and anorexia; suggest
need to avoid systemic adrenergic effects associated with oral sugarless candies or lozenges to relieve some of this
decongestants. discomfort.
 Provide safety measures as appropriate if CNS
Topical nasal steroid decongestants block the inflammatory
effects occur to prevent patient injury.
response and are preferred for patients with allergic rhinitis for
whom systemic steroid therapy is undesirable. Increase humidity and push fluids to decrease the problem of
thickened secretions and dry nasal mucosa.
Have patient void before each dose to decrease urinary reducing the viscosity of these secretions and making it easier
retention if this is a problem. for the patient to cough them up

Parkinsonism  Advice the patient to take small, frequent meals to

alleviate some of the GI discomfort associated with
Parkinsonism is a clinical syndrome characterized by tremor, these drugs.
bradykinesia, rigidity, and postural instability. These are the
 Advise the patient to avoid driving or performing
four motor symptoms found in Parkinson's disease (PD), after
dangerous tasks if dizziness and drowsiness occur to
which it is named, dementia with Lewy bodies (DLB),
prevent patient injury.
Parkinson's disease dementia (PDD), and many other
 Alert the patient that these drugs may be found in
conditions.
over-the-counter preparations and that care should be
Parkinson's is caused mainly by the degeneration of nerve taken to avoid excessive doses.
cells in the brain, while the causes of parkinsonism are
Guaifenesin (Mucinex) is the expectorant typically found in
numerous, ranging from the side effects of medications to
most OTC cold medications. Its use appears to be safe during
chronic head traumas to metabolic diseases to toxins to
pregnancy, with the exception of the first trimester.
neurological diseases.Jan 8, 2020

Contraindications:
CONSIDER THE CATEGORY!
Arrhythmia is a problem with the rate or rhythm of the
heartbeat. During an arrhythmia, the heart can beat too fast,  Guaifenesin is considered pregnancy category C.
too slowly, or with an irregular rhythm. When a heart beats too Guaifenesin has not been studied as extensively as
fast, the condition is called tachycardia other OTC products. In one study of 197 pregnant
women, there was an association between
Contraindications
guaifenesin exposure in the first trimester and an
Nonallergic rhinitis (vasomotor rhinitis) is a condition that increased incidence of inguinal hernias.17 This
causes chronic sneezing, inguinal hernia association was not found in other
guaifenesin studies
Angioedema is an area of swelling of the lower layer of skin
and tissue just under the skin or mucous membranes. The
swelling may occur in the face, tongue, larynx, abdomen, or
Mucolytics are medicines that thin mucus, making it less thick
arms and legs. Often it is associated with hives, which are
and sticky and easier to cough up. They are used to treat
swelling within the upper skin.
respiratory conditions characterized by excessive or thickened
mucus, such as a chesty (productive) cough.

An expectorant is a medication that people can use when they Mucolytics

have a cough that produces mucus. Doctors and pharmacists
refer to these types of cough as “productive” or
“wet.” Expectorants reduce the thickness of mucus and make
secretions in the airways thinner

Expectorant

 not be used in patients with a known allergy to the

drug
 with caution in pregnancy and lactation

Expectorants (Table 54.4) increase productive cough to clear

the airways. They liquefy lower respiratory tract secretions,
Caution should be used in cases of acute bronchospasm,
peptic ulcer, and esophageal varices because
Pneumonia is an infection that affects one or both lungs. It
Dornasealfa is specific for the treatment of patients with cystic causes the air sacs, or alveoli, of the lungs to fill up with fluid or
fibrosis, which is characterized by a thick, tenacious mucus
production that can block airways.

Increase or liquefy respiratory secretions to aid the clearing of

the airways in high-risk respiratory patients who are coughing
up thick, tenacious secretions. Patients may be suffering from
conditions such as chronic obstructive pulmonary disease
(COPD), cystic fibrosis, pneumonia, or tuberculosis. Mucolytics
include acetylcysteine (Mucomyst and others) and dornase
alfa (Pulmozyme).

Contraindications and Cautions

Caution should be used in cases of acute bronchospasm,

peptic ulcer, and esophageal varices because the increased
secretions could aggravate the problem. There are no data on pus. Bacteria, viruses, or fungi may cause pneumonia.
the effects of the drugs in pregnancy or lactation Symptoms can range from mild to serious and may include a
cough with or without mucus (a slimy substance), fever, chills,
and trouble breathing.
DRUGS ACTING ON LOWER REPIRATORY TRACT  Streptococcus pneumoniae germ 
 Mycoplasma pneumoniae, a tiny wide-spread
bacterium that usually infects people younger than 40
years old, especially those living and working in
crowded conditions. The illness is often mild enough
to go undetected and is sometimes referred to as
walking pneumonia.

Chlamydophila pneumoniae, which commonly causes upper

respiratory infections year-round, but can also result in a mild
form of pneumonia.

Legionella pneumophila, which causes a dangerous form of

pneumonia called Legionnaire's disease. Unlike other bacterial
pneumonias, Legionella is not passed from person to person.
Outbreaks of the disease have been linked to exposure to
contaminated water from cooling towers, whirlpool spas, and
outdoor fountains.

The influenza virus is the most common cause of viral

pneumonia in adults. Respiratory syncytial virus (RSV)  is the
most common cause of viral pneumonia in young children.
Most viral pneumonias are not serious and last a shorter time
than bacterial pneumonia.
Bronchiectasis describes the widening (“ectasis”) of some of
the airways. This occurs in patches due to damage caused by Fungal pneumonia is most common in people with chronic
infection. This prevents the effective clearance of mucus which health problems or weakened immune systems, and in people
then increases the chances of further infection and who are exposed to large doses of certain fungi from
inflammation. The smaller airways are thickened and narrowed contaminated soil or bird droppings.
due to the inflammation and this leads to breathlessness.
Macrolide antibiotics: Macrolide drugs are the preferred
treatment for children and adults. Macrolides
include azithromycin (Zithromax®)
and clarithromycin (Biaxin®). Over the past decade, some
strains of Mycoplasma pneumoniae have become resistant to
macrolide antibiotics, possibly due to the widespread use of
azithromycin to treat various illnesses.

Fluoroquinolones: These drugs include ciprofloxacin (Cipro®)

and levofloxacin (Levaquin®). Fluoroquinolones are not
recommended for young children.

Tetracyclines: 

 This group includes doxycycline and tetracycline.

Emphysema is a type of chronic obstructive pulmonary
 They are suitable for adults and older children.
disease (COPD). In this condition, the air sacs in the lungs
become damaged and stretched. This results in a chronic
cough and difficulty breathing.

 Smoking is the most common cause of emphysema,

but other factors can also cause it. There is currently
no cure, but quitting smoking can help improve the
outlook.
 The walls of the air sacs break down or are
destroyed, narrowed, collapsed, stretched, or over-
Asthma inflated. This means that there is a smaller surface
area for the lungs to take oxygen into the blood and
During an acute asthma episode, the airway lining in the lungs remove carbon dioxide from the body.
becomes inflamed and swollen. In addition, mucus production  This damage is permanent and irreversible, but there
occurs in the airway and muscles surrounding the airway are ways of managing the condition.
spasm. Combined, these cause a reduction in air flow.
The inhaler delivers the following bronchodilators:

 beta-agonists, which relax bronchial smooth muscle

Asthma is characterized by: and help clear mucus
 anticholinergics, or antimuscarinics, such as albuterol
• Airway inflammation: The airway lining becomes red, swollen, (Ventolin), which relax bronchial smooth muscle
and narrow. •  inhaled steroids, such as fluticasone, which help
Airway obstruction: The muscles encircling the airway tighten reduce inflammation
causing the airway to narrow making it difficult to get air in and
out of the lungs.

• Airway hyper-responsiveness: The muscles encircling the

airway respond more quickly and vigorously
 BRONCHODILATORS

Bronchitis is an inflammation of the lining of your bronchial

tubes, which carry air to and from your lungs. People who have
bronchitis often cough up thickened mucus, which can be
discolored. Bronchitis may be either acute or chronic.

A bronchodilator is a medication that relaxes and opens the

airways, or bronchi, in the lungs.

Fast-Acting Bronchodilators for COPD

 Albuterol (Ventolin®, Proventil®, AccuNeb®)

 Albuterol sulfate (ProAir® HFA®, ProAir RespiClick)
 Levalbuterol (Xopenex®)

Long acting:

 Formeterol
 salmeterol
 XANTHINES

Neurological: orientation, reflexes, affects coordination

Respiratory: respiratory rate and character, adventitious

sounds Skin: color, lesions

Cardiovascular: blood pressure, pulse, peripheral perfusion,

baseline electrocardiogram

GI: bowel sounds, abdominal exam

Xanthine derivatives also relax the airway muscles, although Laboratory tests:
doctors do not know precisely how they work. The main
xanthine derivative is theophylline.  serum theophylline levels, renal and
 hepatic function tests
 Doctors rarely prescribe theophylline anymore
because many people experience significant side Xanthine derivatives open airways by relaxing the smooth
effects. However, theophylline is available in capsule, muscles in the walls of the airways and they also suppress the
tablet, or liquid form. response of the airways to stimuli. The mechanism of action of
 It is an agent that stimulates sympathetic nervous xanthines is not fully understood. Xanthine derivatives may
fibers, which allow relaxation of smooth muscle in the dilate bronchi by blocking the action of phosphodiesterase
airway. It is also known as sympathomimetic (PDE) enzymes which ultimately leads to increased
bronchodilator or β2 agonist. concentration of chemicals that dilate bronchial airways.

 Beta 2-agonists stimulate beta-adrenoceptors in the It's unclear exactly how theophylline works, but it seems to
airway. This class of bronchodilator causes the reduce any inflammation (swelling) in the airways, in addition
smooth muscles surrounding the airways to relax. to relaxing the muscles lining them.
This improves airflow and reduces symptoms, such
The effect of theophylline is weaker than other bronchodilators
as shortness of breath.
and corticosteroids.
Anticholinergic bronchodilators block the action of
It's also more likely to cause side effects, so is often only used
acetylcholine. Acetylcholine is a chemical released by the
alongside these medicines if they're not effective enough.
nerves that can lead to tightening of the bronchial tubes. By
blocking the chemical, anticholinergic bronchodilators cause
the airways to relax and open.
Novel: Doxofylline (7-(1,3-dioxalan-2-ylmethyl) theophylline) is SYMPATHOMIMETICS
a novel xanthine bronchodilator which differs from theophylline
in that it contains a dioxalane group in position 7. Similarly to These are agents which in general mimic responses due to
theophylline, its mechanism of action is related to the inhibition stimulation of sympathetic nerves.
of phosphodiesterase activities, but in contrast it appears to
have decreased affinities towards adenosine A1 and A2
receptors, which may account for its better safety profile.

Actions: Vital capacity (VC) is the maximum amount of air a

person can expel from the lungs after a maximum inhalation. It
is equal to the sum of inspiratory reserve volume, tidal volume,
and expiratory reserve volume. 

Common side effects of xanthines include:

 Nausea
 Vomiting
 Diarrhea
 Headaches
 Irritability
 Flushing
 Palpitations

Heart arrhythmias

The therapeutic concentration for theophylline, when used as a

bronchodilator to treat asthma, is generally considered to be
5–15 mcg/mL (28-83 micromol/L) for adults, 5–10 mcg/mL
(28–55 micromol/L) for children and neonates. Levels greater
than 20 mcg/mL (111 micromol/L) are considered toxic

Form of capsule or tablet, elixir iv

High serum theophylline levels increase the risk of toxicity. GI upset, cardiac arrhythmias, hypertension, bronchospasm,
Toxic effects include nausea and vomiting, headaches, gastric sweating, pallor, and flushing
discomfort, diuresis, insomnia, cardiac arrhythmias, behavioral
disturbances, and epileptic seizures. Contraindication: Cross the placenta, enters breastmilk,
cardiac disease, vascular disease, arrhythmias, diabetes, and
Multidose activated charcoal (MDAC) enhances elimination of hyperthyroidism.
theophylline. It is important to control nausea and vomiting in
order to perform MDAC treatment It is also known as sympathomimetic bronchodilator or β2
agonist.
Severe Interactions of theophylline include:
Beta 2-agonists stimulate beta-adrenoceptors in the airway.
 dipyridamole This class of bronchodilator causes the smooth muscles
 febuxostat surrounding the airways to relax. This improves airflow and
 riociguat reduces symptoms, such as shortness of breath.

It is not known if theophylline is excreted in breast milk; its The sympathetic division increases heart rate and the force of
effect on nursing infants is not known. Consult your doctor heart contractions and widens (dilates) the airways to
before breastfeeding. make breathing easier.

Fast-Acting Bronchodilators for COPD

Albuterol (Ventolin®, Proventil®, AccuNeb®)

Albuterol sulfate (ProAir® HFA®, ProAir RespiClick)

Levalbuterol (Xopenex®)

Key Points

Short-acting beta 2-agonists are called "reliever" or "rescue"  Teach patients who use one of these drugs for
medicines because they stop asthma symptoms very quickly exercise-induced asthma to use it 30 to 60 minutes
by opening the airways. These are the best medications for before exercising
treating sudden and severe or new asthma symptoms. They
work within 15 to 20 minutes and last four to six hours. They  Alert patient that long-acting adrenergic blockers are
are also the medicines to use 15 to 20 minutes before exercise not for use during acute attacks
to prevent exercise-induced asthma symptoms. If you need to
use your short-acting beta 2-agonists more than twice per  Provide safety measures as needed if CNS effects
week, talk to your doctor. This is a sign of unstable asthma and
your doctor may want to change the dose of the long-term  Provide small, frequent meals and nutritional
control medicines you take. consultation if GI effects interfere with eating to
ensure proper nutrition
Beta 2-agonists - Long-acting forms include:

 Salmeterol (Serevent®)
Anticholinergic
 Formoterol (Foradil®)

Combination medications: salmeterol and fluticasone

(Advair®); formoterol and budesonide (Symbicort®); formoterol
and mometasone (Dulera®). These contain both the long-
acting beta agonist and an inhaled corticosteroid.

Salmeterol and formoterol are the only inhaled long-acting beta

2-agonists available. They are used twice a day to maintain
open airways for long-term control and they must be used with
an inhaled corticosteroid for the treatment of asthma. They
have also been shown to be helpful in treating exercise-
induced asthma. They are available in dry powder inhaler
(DPI) form.

Side effects of beta 2-agonists include:

 Nervous or shaky feeling

 Overexcitement or hyperactivity Contraindication in the presence of known allergy to the drug
 Increased heart rate or to soy products or peanuts (the vehicle used to make
 Upset stomach (rare) ipratropium an aerosol contains a protein associated with
 Trouble sleeping (rare) peanut allergies.

Anticholinergic bronchodilators block the action of

acetylcholine. Acetylcholine is a chemical released by the
Albuterol also is available in pills or syrups. These medicines nerves that can lead to tightening of the bronchial tubes. By
tend to have more side effects because they are in higher blocking the chemical, anticholinergic bronchodilators cause
doses and are absorbed through the bloodstream to get to the the airways to relax and open.
lungs. Inhaled forms are preferred because they are deposited
directly in the lungs and therefore have fewer side effects. Anticholinergic (also known as antimuscarinics) are mainly
used to treat COPD, but a few can also be used for asthma.

 They're usually taken using an inhaler, but may be

Preterm labor: terbutaline is a tocolytic used to delay preterm nebulized to treat sudden and severe symptoms.
labor for up to 48 hours.  Anticholinergic cause the airways to widen by
blocking the cholinergic nerves.
 These nerves release chemicals that can cause the
muscles lining the airways to tighten.
There are two anticholinergic bronchodilators currently
available —
Inhaled steroids
Ipratropium bromide (Atrovent® HFA), which is available as a
metered dose inhaler and nebulizer solution, and Ipratropium
is used four times per day.

tiotropium bromide (Spiriva®), which is a dry powder inhaler.

Tiotropium is used only once per day and lasts 24 hours. It
should be used at the same time every day. These are not
quick-relief medications but they can add to the bronchodilator
effect for certain asthmatics with difficult-to-control symptoms.

Side effects are minor; dry throat is the most common. If the

medicine gets in your eyes, it might cause blurred vision for a
short period of time.

They should be used with caution in people with:

• benign prostate enlargement – where the prostate

gland becomes enlarged, which can affect how you
pee

• a bladder outflow obstruction – any condition that

affects the flow of urine out of the bladder, such
as bladder stones or prostate cancer
Contraindication: used cautiously in patients with hepatic or
• glaucoma – a build-up of pressure in the eye renal impairment because these conditions can affect the
drug’s metabolism and excretion. Fetal toxicity has been
If you have benign prostate enlargement or a bladder outflow
reported in animal studies, so these drugs should be used
obstruction, anticholinergic can cause problems, such as
during pregnancy
difficulty peeing and not being able to empty your bladder fully.
Inhaled steroids: The key treatments for asthma are steroids
Glaucoma can get worse if anticholinergic medication
and other anti-inflammatory drugs. These asthma drugs both
unintentionally gets into the eyes.
help to control asthma and prevent asthma attacks.
Atrovent (an anticholinergic bronchodilator) is used to treat
Steroids and other anti-inflammatory drugs work by reducing
COPD. It is available as an inhaler and also in a nebulizer
inflammation, swelling, and mucus production in the airways of
solution. A dry throat is the most common side effect. If the
a person with asthma. As a result, the airways are less
medication gets in the eyes, it may cause blurred vision for a
inflamed and less likely to react to asthma triggers , allowing
short period of time.
people with symptoms of asthma to have better control over
Revefenacin (Yupelri) is a new medication used daily to help their condition.
those with COPD breathe easier. Long-acting, it is taken once
a day with a nebulizer.
Side effects of steroid inhalers
A long-acting anticholinergic inhaler, tiotropium bromide
• A sore mouth or throat.
(Spiriva Respimat) may be used by asthmatics and those with
COPD. For treating asthma, people 6 years of age and older • A hoarse or croaky voice.
may use this medication once daily as a long-term
maintenance drug. For COPD, this drug may be used as a • A cough.
long-term maintenance medication and for treating COPD
exacerbations when airway obstruction persists after an • Oral thrush – a fungal infection that causes white
inhaled bronchodilator. patches redness and soreness in the mouth.

• Nosebleeds.

The best practices below will help you avoid oral thrush and
keep your asthma symptoms from returning.
 • Use your inhaled steroids every day, even if you’re Leukotrienes are inflammatory chemicals
not experiencing asthma symptoms. the body releases after coming in contact with an allergen
or allergy trigger. Leukotrienes cause tightening of airway
• Use a spacer device with a metered dose, if
instructed to do so by your doctor. muscles and the production of excess mucus and fluid

• Rinse your mouth with water immediately after using  Leukotriene receptor antagonists (LTRA) are a new
the inhaler. class of drugs for asthma treatment, available in
tablet form. Their unique mechanism of action results
• See your doctor if you develop oral thrush.
in a combination of both bronchodilator and anti-
inflammatory effects.

Leukotriene Receptor Antagonists  Montelukast is a potent, specific leukotriene receptor

antagonist. Administered once daily in tablet
form, montelukast reduces the signs and symptoms
of chronic asthma in adults and children as young as
6 years of age, with a tolerability profile similar to that
of placebo.

Lung Surfactant

Caution: Empty Stomach

Use caution if propranolol, theophylline, terfenadine, or

warfarin is taken with these drugs because increased toxicity
can occur. Calcium channel blockers, cyclosporine, or aspirin; Because lung surfactants are used as emergency drugs in the
decreased dose of either drug may be necessary newborn, there are no contraindications

Contraindication: Adverse effects: bradycardia, hypotension, intraventricular

hemorrhage, pneumothorax, pulmonary air leak,
 hepatic or renal impairment hyperbilirubinemia, and sepsis.

 Fetal toxicity This substance lowers surface tension, which keeps the alveoli
from collapsing after exhalation and makes breathing easy.
 Not indicated for the treatment of acute asthmatic
attacks, because they do not provide any immediate  Beractant- Survanta
effects on the airways.  Calfactant- Infasurf
 Poractant- Curosurf
The lungs of preterm babies with RDS are both anatomically
and biochemically immature; they neither synthesize nor
secrete surfactant well. Surfactant normally lines the alveolar
surfaces in the lung, thereby reducing surface tension and
preventing atelectasis.

If surfactant levels are low, the alveoli do not expand and

cannot receive air, leading to decreased gas exchange, low
oxygen levels, and generalized distress throughout the body
as cells do not receive oxygen that they need to survive.

Preterm is defined as babies born alive before 37 weeks of

pregnancy are completed. There are sub-categories
of preterm birth, based on gestational age:
extremely preterm (less than 28 weeks) very preterm (28 to 32
weeks) moderate to late preterm (32 to 37 weeks).

• Assess for possible contraindications and cautions:

screen for the time of birth and exact weight to
determine appropriate doses; because this drug is
used as an emergency treatment, there are no
contraindications to screen for.

• Perform a physical examination to establish baseline

data for assessing the effectiveness of the drug and
the occurrence of any adverse effects associated with
drug therapy.

• Assess the skin temperature and color to evaluate

perfusion.

• Monitor respirations, adventitious sounds,

endotracheal tube placement and patency, and chest
movements to evaluate the effectiveness of the drug
and drug delivery.

• Evaluate blood pressure, pulse, and arterial pressure

to monitor the status of the infant.

• Evaluate blood gases and oxygen saturation to

monitor drug effectiveness.

• Assess temperature and complete blood count to

monitor for sepsis.