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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.jpg

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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