Bronchodilators and Other Respiratory Agents

Asthma -Predominantly in boys 2:1 -puberty: occurrence equals out -More females in adult-onset

cases -Affects ~25 million people (7

million children)2

Chronic Obstructive Pulmonary Disease (COPD)

-A reactive airway disease -Primarily affects older persons

especially smokers and those chronically

exposed to pollutants

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Antigen -> the body, combines with mast cells

-> sensitized mast cellWhen re-exposed to the antigen, there

is the formation and release of chemical substances

-Histamine -Leukotrienes

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Acts directly or indirectly Directly-causes

bronchoconstriction Indirectly-stimulates release

of acetylcholine causes smooth muscle contraction

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used to relax and open the airways, open /maintain the bronchial airways

Treat several disease syndromes Chronic obstructive pulmonary disease

Asthma6

Sympathomimetic agentsXanthine bronchodilators Anticholinergics Leukotriene receptor antagonists5-lipoxygenase inhibitorsMast cell stabilizersCorticosteroids

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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.

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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.

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Beta2-adrenergic receptors

Used during the acute phase of asthmatic attacks

Quickly reduce airway constriction and restore normal airflow

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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

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Nonselective adrenergics Stimulate alpha1, beta1

(cardiac), and beta2 (respiratory) receptors

Example: epinephrine/Primatene or Adrenaline

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Nonselective beta-adrenergics Stimulate both beta1, beta2

receptors isoproterenol (Isuprel)

Selective beta2 drugs albuterol/Proventil or Ventolin Levalbuterol/Xopenex

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Frequent use leads to beta1 receptors being stimulated Albuterol loses its action

General side effects Nausea, increased anxiety, palpitations, tremors, and increased heart rate

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Chemical class of agentsContain caffeine

Oldest class of bronchodilatorsUsed in ancient times

Examples: Aminophylline , Theophylline, Theolair, Elixophyllin, Slo-Phyllin, Theo-Dur, Theo24

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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 effects16

Nausea, vomiting, anorexia GERD during sleep Sinus tachycardia, extrasystole

(PVC’s), palpitations Nervousness/restlessness,

convulsions Smokers may require higher and

more frequent doses17

Monitor patient for tachycardia Educate: reduce caffeine Monitor CNS stimulation, changes

in cardiac function, seizures Serum theophylline levels required

Therapeutic Range 10-20mcg/mL

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Acetylcholine (ACh) causes bronchial constriction.

Anticholinergics bind to the ACh receptors, preventing ACh from binding.

Result: bronchoconstriction is prevented, airways dilate

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Ipratropium bromide (Atrovent)Tiotropium bromide (Spiriva HandiHaler)Actions

Local effects Slow and prolonged action Used to prevent bronchoconstriction Not used for acute asthma exacerbations!

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Usually not absorbed systemically

If absorbed, may produce: Dry mouth or dry throat Gastrointestinal distress Headache Coughing Anxiety

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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

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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

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Montelukast (Singulair)

Zafirlukast (Accolate)

Class side effects:

Headache Nausea Diarrhea Liver dysfunction

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Use for chronic management of asthma, not acute asthma

Improvement should be seen in about 1 week

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New class of LRAs Action

Inhibit the formation of leukotrienes

Used to inhibit some cancer growth

Outcome Prevent lung inflammation

Example: Zileuton26

Prophylactic Indirect bronchodilator activity Stabilize cell membranes of

inflammatory cells mast cells, monocytes,

macrophages

Prevent release of harmful cellular contents

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Adjuncts to the overall management of clients with lung disease

Prevent bronchospasm when exposed to:Cold airExerciseAllergens Dry air

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Cromolyn (Nasalcrom, Intal)

Nedocromil (Tilade)

Side effects: Coughing Taste changes Sore throat Dizziness Rhinitis Headache Bronchospasm

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Anti-inflammatory Inhaled forms

Reduce systemic effects Used for chronic asthma

Does not relieve acute asthma

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Stabilize membranes of cells that release harmful bronchoconstricting substances

Also increase responsiveness of bronchial smooth muscle to beta-adrenergic stimulation

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Beclomethasone dipropionate (Beclovent, Vanceril)

Triamcinolone acetonide (Azmacort)

Flunisolide (AeroBid)

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Pharyngeal irritation Coughing Dry mouth Oral fungal infections: rinse the

mouth after administration Systemic effects are rare

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Combination productFluticasone propionate and salmeterol (Advair): a dry powder in a circular discus

Salmeterol: long-acting bronchodilatorFluticasone propionate: Corticosteroid: anti-inflammatory agentUsed daily Q12hrs

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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 occurs35

Do not wear perfume of colognes Do not use talc or baby powder If patient is on oxygen, safety

measures need to be taught

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flu and pneumonia vaccination prompt treatment for any

illness check with health care

provider before taking other medications

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