Post on 03-Apr-2018
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Caring For the Client withObstructive Pulmonary Disease:
Pharmacologic Principles
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Obstructive Pulmonary DiseaseAn Umbrella Term
Asthma Emphysema
Chronic Bronchitis
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Obstructive Pulmonary Disease:Pharmacology
Two Major Groups of Drugs
Bronchodilators
Prevent/treat bronchoconstriction
Anti-inflammatory agents Prevent/treat inflammation
inflammation will also bronchoconstrictionby:
mucosal edema
mucous secretion
hyperreactivity to various stimuli
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Question:If you were giving both abronchodilator and an anti-
inflammatory to the client,which would you give first?
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GENERIC NAME TRADE NAME CLASSIFICATION ROUTEalbuterol Proventyl Short-term beta
agonist
inhaled
levalbuterol Xopenex Longer-term betaagonist
inhaled
ipratropium Atrovent Anticholingergic inhaled
tiotropium Spireva Anticholingeric inhaled
theophylline Theodur Methylxanthine po
beclomethasone Beclovent Glucocorticoid
(steroid)
inhaled
prednisone Prednisone Glucocorticoid
(steroid)
po
zafirlukast Accolate Leukotriene
modifier
po
montelukast Singulair Leukotriene
modifier
po
cromolyn Intal Mast cell stabilizer inhaled
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Bronchodilators: Classifications
Beta-agonists
Anticholinergics
Methylxanthines
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What is a beta agonist???
Clinical consequences of beta activation
Lehne, Ch.17, p.155
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Nervous System
Central Peripheral
AutonomicSomatic
(Skeletal Muscle)
Brain Spinal cord
Parasympathetic
(cholinergic) ACh
Sympathetic
(adrenergic) NE
Nicotinic
Muscarinic
Alpha &
Beta &
Beta receptors mainly in heart;
Beta receptors mainly in lungs
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Repeat after me
SympathomimeticAnticholinergicExacerbation
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Beta-agonists: 3 Classifications
Nonselective adrenergic drugs (Stimulate alpha, beta & beta)
Nonselective beta-adrenergic drugs (Stimulate beta & beta)
Selective beta drugs (Stimulate only beta receptors)
For a beta-agonist to dilate the airways oflungs, it must stimulate beta-adrenergicreceptors located throughout the lungs
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Beta-agonists
MOA:
If stimulate beta receptors:
rate/force of ventricular contraction (may be anadverse effect when given for bronchodilation)
If stimulate beta-adrenergic receptors:
relaxation of smooth muscle in bronchi/bronchioles
If stimulate alpha receptors:
vasoconstriction
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Beta-agonists
Indications for Use: Treatment of bronchial asthma, bronchitis, emphysema
Adverse Effects: Selective beta agonists
Minimal; tremors (Alpha-beta agonists most adverse effects)*
Insomnia, restlessness, anorexia, cardiac stimulation, tremor,vascular headache
(Nonselective beta-agonists limited to beta-adrenergiceffects)*
Cardiac stimulation, tremor, anginal pain, vascular headache
*Need Not Know For Exam
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Beta-agonists: Common Drugs
albuterol (Proventil, etc) ** Short-acting beta agonist
Inhalation first line of treatment for acute asthmaattack
PO Proventil Repetabs; used for long-term moderateto severe asthma; not to be used for exacerbations
Also seeing @ CHRH levalbuterol (Xopenex)
epinephrine (Primatene, etc) Nonselective alpha beta agonist
Inhalation Also SQ epinephrine
metaproterenol (Alupent, etc) Nonselective beta agonist
Inhalation** PROTOTYPE
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Use of more than one canister per
month indicates inadequate control of
asthma & need for initiating or
intensifying anti-inflammatory therapy
Regularly scheduled daily use is
not recommended
* Also for prevention of EIA
Albuterol Inhaler: Treatment Of ChoiceFor Acute Asthma Attack
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MOA:Blocks the action of acetylcholine in
bronchial smooth muscle when given by
inhalation bronchodilationActions are slow and prolonged
Indications for Use:
Used prophylactically/maintenance ofemphysema & bronchitis
Treatment of asthma (off label)
Anticholinergics
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Action Sites ofAnticholinergics
Heart Lungs
GItract
Bladder
Eye
Exocrine
glands
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Anticholinergics
Adverse Effects:
Dry mouth, GI distress, H/A, cough, anxiety
Common Drugs:
ipratropium bromide (Atrovent) ** (qid)
Works synergistically with beta agonists; may be givenconcomitantly
Combivent (inhalation)
A product that contains both albuterol & ipratropium
tiotropium bromide (Spiriva) (Feb, 2004)*
First once-daily maintenance therapy for COPD
** Prototype
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Methylxanthines
MOA:
Bronchodilation 2 smooth muscle relaxation
Also stimulate CNS & CVS (esp. heart)
Indications for Use:
Second-line agent may be added in severeOPD (all 3)
Adverse Effects: Toxicity: N/V/D, insomnia, H/A, tachycardia,
dysrrhythmias, seizures (especially in elderly)
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Common Drugs:
theophylline (TheoDur, others) **
PO, IV or rectal
Take with food
Caffeine may side effects
Smoking absorption
Narrow therapeutic index
Maintain serum level 5-15 mcg/ml**PROTOTYPE
Methylxanthines
A ti i fl t A t
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Anti-inflammatory Agents:Classifications
Corticosteroids/Glucocorticoids
Leukotriene Modifiers
Mast cell stabilizers
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Most potent & effective anti-inflammatory
medication currently available
MOA:
1. Suppress inflammation in airways by:
movement of fluid/protein into tissues
migration/function of neutrophils/eosinophils
synthesis of histamine in mast cells
production of pro-inflammatory substances
2. number/sensitivity of beta adrenergic
receptors to bronchodilators
Corticosteroids
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Corticosteroids
Indications for Use:
Inhaled form:
Cornerstone of asthma therapy (long-term control)
(Not typically indicated for tx of COPD)
Advantage limited to topical site of action the lungs
Systemic (IV or PO) form:
Used to gain prompt control of asthma when initiating
long-term therapy
Early stages of COPD unlikely to need; however, need
short-course therapy for episodes of respiratory distress
(PO/IV)
End-stage COPD often become steroid-dependent
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Corticosteroids
Usedregularly to prevent symptoms (even ifasymptomatic)
Used for maintenance therapy (not acuteattacks)
Adverse Effects:
Inhalation
Limited 2 route (sore throat, dry mouth, infection)
Teach client to rinse mouth after each administration to potential for fungal infections (ie, candidiasis*) of themouth
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Oropharyngealcandidiasis
thrush
Treatment:
Anti-fungal agent
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Common Drugs: Inhalation (Meter-Dose Inhaler)
beclomethasone dipropionate (Beclovent, Vanceril) **
triamcinolone acetonide (Azmacort)
Systemic (PO/IV) prednisone (Prednisone)
hydrocortisone (Solu-Cortef)
methylprednisolone (Solu-Medrol)
Take with food Follow dosing schedule exactly
3-10 day course of treatment (Lehneacute use)
PROTOTYPE **
Corticosteroids
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New class of asthma medication; first in over 20
years
Leukotrienes Cause inflammation,
bronchoconstriction, & mucous production
MOA:
Prevent leukotrienes from attaching to
receptors (block inflammation); either (1)inhibits enzymes, (2) proteins or (3) blocks
receptors
Leukotriene Modifiers
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Leukotriene Modifiers
Indications for Use:
Oral prophylaxis & chronic treatment of
asthma in adults & children 6 years old
Not meant for acute asthma attacks
Adverse Effects:
Headache, dyspepsia, nausea, dizziness,
insomnia
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Common drugs (oral): zafirlukast (Accolate)** - for adults
montelukast (Singulair)for children
pranlukast (Ultair)
zileuton (Zyflo)
Improvement seen 1 week
Singulair q day med for children;
take at HS for nighttime symptoms;PO & chewable; take in a.m. forallergy control; if for both asthmaand allergy, take at night
**PROTOTYPE
Leukotriene Modifiers
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MOA:
Stabilize membranes of mast cells & prevent
release of bronchoconstrictive/ inflammatory
substances when mast cells are confronted with
allergens/other stimuli
Indications for Use:
Used forprophylaxis of acute asthma attacks inclients with chronic asthma (prior to exercise or
known allergen)
Mast Cell Stabilizers
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Caring For The Client With Asthma:
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Goals of ASTHMA therapy:
Prevent chronic & troublesome symptoms
Maintain (near) normal PFTs Maintain normal activity levels
Prevent recurrent exacerbations of
asthma/minimize need for ER visits
Meet clients expectations of asthma care
Taken from The Guidelines for the Diagnosis & Management
Of Asthma: Expert Panel Report 2, 1997
Caring For The Client With Asthma:Special Considerations
Pharmacology of Asthma:
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Pharmacology of Asthma:A Stepwise Approach
Amount & frequency of medication is dictated by
asthma severity/directed toward suppression of
increasing airway inflammation
Initiate therapy at a higher level at the onset to
establish prompt control and then step down
Continual monitoring is essential to ensure asthma
control(Peak flow meter)
Step down therapy cautiously once control is
achieved/sustained
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Peak Flow Meter: Find Your Personal Best/FEV: Lehne, .878
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Peak Flow Meter: Purposes
Learn what makes asthma worse
Decide if treatment is working well
Decide when to add/stop medication
Decide when to seek medical
attention
Asthma Pharmacology:
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Asthma Pharmacology:More Key Points
Step down therapy is necessary to
identify the minimum medication
necessary to maintain control
Regular follow-up visits (q 1-6 months)
Client education is ESSENTIAL
Client should be advised to avoid
allergens
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Two Categories of Medications Usedto Prevent & Treat OPD,
(Particularly Asthma)
1. Long-term control medications
AKA:
Long-term preventive
Controller
Maintenance
2. Quick-relief medications
AKA:
Reliever
Acute rescue
See Lehne, p. 877, Table 74-5
Special Considerations:
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Special Considerations:Different Age Groups
Infants/young children:
Diagnosis is difficult, but essential
If receiving symptomatic treatment > 2times/wk, anti-inflammatory meds indicated
Trial of cromolyn or nedocromil given (2
safety profile)
Response to therapy should be carefully
monitoredstep down in therapy if possible
Special Considerations:
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School-Age Children & Adolescents
Mild-to-moderate persistent asthma initiate
trial of cromolyn or nedocromil Should be directly involved in establishing goals
for therapy and developing their asthma
management plans
Active participation in physical activities,exercise & sports should be promoted
Written asthma plan students school
Special Considerations:Different Age Groups
Special Considerations:
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Older Adults
Asthma meds may aggravate coexisting
medical conditions (e.g., cardiac disease,
osteoporosis, etc)
Be aware of potential for adverse
drug/disease interaction (e.g., NSAIDS,
beta-blockers) Review of client technique in using
medications & devices is essential
Special Considerations:Different Age Groups
OPD Medications:
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OPD Medications:Routes of Administration
Two routes:
1. Inhaled (aerosols) Major advantages:
Higher concentrations can be delivered moreeffectively to airways
Systemic adverse effects are avoided orminimized
Onset of inhaled bronchodilators < oral
bronchodilators (5-15 minutes)
Rinse & spit following inhalation
2. Systemic Oral or parenteral
Inhaled Medications:
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Inhaled Medications:A Variety of Devices
Metered-dose inhaler (MDI)
Actuation during a slow, deep inhalation (3-5 secs)
followed by 10-second breath-holding; wait one minute
between each puff; do bronchodilatorbefore anti-
inflammatory agent
Open-mouth technique (1-2 inches) vs. closed-mouth
technique
Population: > 5 years
Medicine propelled by chlorofluorocarbons (CFCs)
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CFCs damage ozone
layer; being phasedout; CFC inhalers
obsolete after 2005(???)
Inhaled Medications:
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Breath-actuated MDI
Slow inhalation (3-5 secs) - followed by 10-
second breath-holding; 400 inhalations/cannister
Indicated for clients unable to coordinate
inhalation and actuation/cannot be used with
spacer/holding chamber devices
Population: > 5 years
Maxair Autohaler: only breath-actuated
MDI in U.S. market
Inhaled Medications:A Variety of Devices
Inhaled Medications:
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Dry powder inhaler (DPI)
Rapid (1-2 secs), deep inhalation; dose lost if
client exhales through device
Population: > 4-5 years
Inhaled Medications:A Variety of Devices
Inhaled Medications:
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Pulmicort Turbuhaler
HandiHaler
Inhaled Medications:A Variety of Devices
Inhaled Medications:
http://www.pfizer.se/upload/Bildarkivet/produkter/spiriva/HandiHaler.jpghttp://www.lungespezial.de/0903/asthma_forschung/images/anwendung%20turbohaler%203_small.jpg7/29/2019 OPDPharm
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Spacer/holding chamber(Lehne, Figure 74-2, p. 869)
Slow (3-5 secs) inhalation or tidal
breathing immediately following
actuation
Easier to use than MDI alone
Recommended for anyone using MDI
Population: > 4 years, 4 years with
face mask
Inhaled Medications:A Variety of Devices
Inhaled Medications:
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Nebulizer(Lehne, pp.867-8)
Slow tidal breathing with occasional deep breaths;
tightly fitting face mask for those unable to use
mouthpiece
Less dependent on client coordination/cooperation
Delivery method of choice for cromolyn in children & for
high-dose beta agonists/anticholinergics in moderate-
to-severe exacerbations in all clients
Inhaled Medications:A Variety of Devices
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Comparison of Inhalation Techniques:
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Comparison of Inhalation Techniques:(Also see Figure 74-2, p.869)
Unsatisfactory Technique Excellent Technique
H f ll i i t ?
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How full is my canister?
Evidence-based Practice Indicating Inaccurate TechniqueBetter Technique: Calculate actuations/day (200/cannister)
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Lehne:
Summary of Major Nursing Implications
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MDI With Face Mask & Spacer
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Exhale
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Closed-Mouth Technique
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Slow, Deep Inhalation for 3-5 Seconds
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Followed by 10 second Breath-holding
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THE END