Bronchodilators and Other Respiratory Agents

1. Bronchodilators and Other Respiratory Agents

2. Asthma -Predominantly in boys 2:1 -puberty: occurrence equals out -More females in adult-onset cases -Affects ~25 million people (7 million children) Asthma

3. Chronic Obstructive Pulmonary Disease (COPD) -A reactive airway disease -Primarily affects older persons especially smokers and those chronically exposed to pollutants COPD

4. Antigen -> the body, combines with mast cells -> sensitized mast cell When re-exposed to the antigen, there is the formation and release of chemical substances -Histamine -Leukotrienes Bronchoconstriction

5. Acts directly or indirectly • Directly-causes bronchoconstriction • Indirectly-stimulates release of acetylcholine • causes smooth muscle contraction Brochoconstriction

6. used to relax and open the airways, open /maintain the bronchial airways Treat several disease syndromes • Chronic obstructive pulmonary disease • Asthma Bronchodilators

7. Sympathomimetic agents Xanthine bronchodilators Anticholinergics Leukotriene receptor antagonists 5-lipoxygenase inhibitors Mast cell stabilizers Corticosteroids Classes of Bronchodilators

8. Stimulation of β1 receptors by epinephrine induces a positive chronotropic and inotropic effect on the heart and increases cardiac conduction velocity and automaticity Stimulation of β1 receptors on the kidney causes renin release. Beta Receptors

9. Stimulation of β2 receptors induces smooth muscle relaxation (resulting in vasodilation and bronchodilation amongst other actions), induces tremor in skeletal muscle, and increases glycogenolysis in the liver and skeletal muscle. Beta Receptors

10. Beta2-adrenergic receptors Used during the acute phase of asthmatic attacks Quickly reduce airway constriction and restore normal airflow Sympathomimetics

11. Treat acute attacks/prevent attacks Quickly reduce airway constriction Relief of bronchospasm, bronchial asthma, bronchitis, and other pulmonary diseases Treat hypotension and shock Produce uterine relaxation to prevent premature labor Uses for Sympathomimetics

12. Nonselective adrenergics • Stimulate alpha1, beta1 (cardiac), and beta2 (respiratory) receptors • Example: epinephrine/Primatene or Adrenaline Sympathomimetic Agents

13. Nonselective beta-adrenergics • Stimulate both beta1, beta2 receptors • isoproterenol (Isuprel) Selective beta2 drugs • albuterol/Proventil or Ventolin • Levalbuterol/Xopenex Sympathomimetic Agents

14. Frequent use leads to beta1 receptors being stimulated • Albuterol loses its action • General side effects • Nausea, increased anxiety, palpitations, tremors, and increased heart rate Sympathomimetic Agents

15. Chemical class of agents Contain caffeine Oldest class of bronchodilators Used in ancient times Examples: Aminophylline , Theophylline, Theolair, Elixophyllin, Slo-Phyllin, Theo-Dur, Theo24 Xanthines

16. Increase levels of energy-producing cAMP • Inhibit phosphodiesterase • Enzyme that breaks down cAMP Result: • Smooth muscle relaxation • Bronchodilation • Increase airflow (oxygen/carbon dioxide) in the lungs • cardiac life-threatening side effects Xanthine Bronchodilators: Mechanism of Action

17. Nausea, vomiting, anorexia GERD during sleep Sinus tachycardia, extrasystole (PVC’s), palpitations Nervousness/restlessness, convulsions Smokers may require higher and more frequent doses Xanthine Derivatives: Side Effects

18. Monitor patient for tachycardia • Educate: reduce caffeine • Monitor CNS stimulation, changes in cardiac function, seizures • Serum theophylline levels required • Therapeutic Range 10-20mcg/mL Xanthines: Nursing Considerations

19. Acetylcholine (ACh) causes bronchial constriction. Anticholinergics bind to the ACh receptors, preventing ACh from binding. Result: bronchoconstriction is prevented, airways dilate Anticholinergics: Mechanism of Action

20. Ipratropium bromide (Atrovent) Tiotropium bromide (Spiriva HandiHaler) Actions • Local effects • Slow and prolonged action • Used to prevent bronchoconstriction • Not used for acute asthma exacerbations! Anticholinergic Bronchodilators

21. Usually not absorbed systemically • If absorbed, may produce: • Dry mouth or dry throat • Gastrointestinal distress • Headache • Coughing • Anxiety Anticholinergics: Side Effects

22. Directly prevent bronchoconstriction • Developed to treat asthma; popular and effective • Leukotrienes are inflammatory molecules • Released by mast cells • Cause the bronchioles to contract • Development of edema in the lungs Leukotriene Receptor Antagonists

23. By blocking leukotrienes: • Prevent smooth muscle contraction of the bronchial airways • Decrease mucus secretion • Prevent vascular permeability • Decrease neutrophil and leukocyte infiltration to the lungs Leukotriene Receptor Antagonists

24. Leukotriene Receptor Antagonists Montelukast (Singulair) Zafirlukast (Accolate) Class side effects: • Headache • Nausea • Diarrhea • Liver dysfunction

25. Use for chronic management of asthma, not acute asthma • Improvement should be seen in about 1 week LRA: Client Education

26. New class of LRAs • Action • Inhibit the formation of leukotrienes • Used to inhibit some cancer growth • Outcome • Prevent lung inflammation Example: Zileuton 5-Lipoxygenase Inhibitors

27. Prophylactic • Indirect bronchodilator activity • Stabilize cell membranes of inflammatory cells • mast cells, monocytes, macrophages • Prevent release of harmful cellular contents Mast Cell Stabilizers

28. Adjuncts to the overall management of clients with lung disease • Prevent bronchospasm when exposed to: Cold air Exercise Allergens Dry air Mast Cell Stabilizers

29. Mast Cell Stabilizers • Cromolyn (Nasalcrom, Intal) • Nedocromil (Tilade) Side effects: • Coughing • Taste changes • Sore throat • Dizziness • Rhinitis • Headache • Bronchospasm

30. Anti-inflammatory • Inhaled forms • Reduce systemic effects • Used for chronic asthma • Does not relieve acute asthma Inhaled Corticosteroids

31. Stabilize membranes of cells that release harmful bronchoconstricting substances Also increase responsiveness of bronchial smooth muscle to beta-adrenergic stimulation Inhaled Corticosteroids

32. Beclomethasone dipropionate (Beclovent, Vanceril) Triamcinolone acetonide (Azmacort) Flunisolide (AeroBid) Inhaled Corticosteroids: Examples

33. Pharyngeal irritation Coughing Dry mouth Oral fungal infections: rinse the mouth after administration Systemic effects are rare Inhaled Corticosteroids: Side Effects

34. Combination product Fluticasone propionate and salmeterol (Advair): a dry powder in a circular discus Salmeterol: long-acting bronchodilator Fluticasone propionate: Corticosteroid: anti-inflammatory agent Used daily Q12hrs Respiratory Agents

35. Assess: respiratory distress?, cardiac status Frequent mouth care Education: meds, proper use of inhalers, breathing control, avoidance of respiratory infections, reduce of environmental pollutants Take with food if GI upset occurs Nursing Considerations

36. Do not wear perfume of colognes Do not use talc or baby powder If patient is on oxygen, safety measures need to be taught Nursing Considerations

37. flu and pneumonia vaccination • prompt treatment for any illness • check with health care provider before taking other medications Respiratory Agents: Client Education