Sinusitis

An inflammation of the mucous membranes of one or more of the maxillary,

frontal, ethmoid, or sphenoid sinuses.
A systemic or nasal decongestant may be indicated. Acetaminophen, fluids,
and rest may also be helpful.
For acute or severe sinusitis, an antibiotic may be prescribed.

Acute Pharyngitis
An inflammation of the throat (sore throat), can be caused by virus, betahemolytic streptococci (strep throat), or other bacteria.
It can occur alone or with the common cold and rhinitis or acute sinusitis.
Symptoms: temperature, cough
Throat culture to rule out beta-hemolytic streptococcal infection.
If (+)beta-hemolytic streptococci, a 10-day course of antibiotics is often
prescribed.
Saline gargles, lozenges, and OFI are usually indicated.
Acetaminophen are usually taken to decrease an elevated temperature.

Drugs for Lower Respiratory Disorders

2 Major Categories of Lower Respiratory Tract Disorders
1) Restrictive Lung Disease a decrease in total lung capacity as a result of
fluid accumulation or loss of elasticity of the lung.
2) Chronic Obstructive Pulmonary Disease (COPD) - caused by airway
obstruction with increased airway resistance of airflow to lung tissues. Four
major pulmonary disorders cause COPD:
ASTHMA
Is an inflammatory disorder of the airway walls associated with a varying
amount of airway obstruction.
When activated by stimuli (stress, allergens, pollutants), the bronchial
airways become inflamed and edematous. This inflammation causes
bronchial cells to produce more mucous, which obstructs air passage that
contributes to wheezing, coughing, dyspnea (breathlessness), and tightness
in the chest, particularly at night or early morning.
CHRONIC BRONCHITIS
Progressive lung disease caused by smoking or chronic lung infections.
Hypercapnia (increased CO2 retention) and hypoxemia (decreased blood O2)
lead to respiratory acidosis.
BRONCHIECTASIS
Abnormal dilation of the bronchi and bronchioles 2 frequent infection and

inflammation.

Bronchioles become obstructed by the breakdown of the epithelium of

the bronchial mucosa.
Tissue fibrosis may result.
EMPHYSEMA
Progressive lung disease caused by cigarette smoking, atmospheric
contaminants, or lack of the alpha1-antitrypsin protein that inhibits proteolytic
enzymes that destroy alveoli (air sacs).
Alveoli enlarge, air becomes trapped in the overexpanded alveoli leading to
inadequate gas exchange.
Medications frequently prescribed for COPD include the ff.:
Bronchodilators such as sympathomimetics (adrenergics),
parasympatholytics (anticholinergic drug Atrovent), and methylxanthines
(caffeine,theophylline) used to assist in opening narrowed airways,
Glucocorticoids (steroids) used to decrease inflammation.
Leukotriene modifiers reduce inflammation in the lung tissue
Cromolyn and nedocromil act as anti-inflammatory agents by suppressing
the release of histamine and other mediators from the mast cells.
Expectorants used to assist in loosening mucus from the airways.
Antibiotics to prevent serious complications from bacterial infections.
BRONCHIAL ASTHMA
COPD characterized by periods of bronchospasm resulting in wheezing and
difficulty breathing.
Bronchospasm (bronchoconstriction) results when the lung tissue is exposed
to extrinsic or intrinsic factors that stimulate a bronchoconstrictive response.
Factors include :
ENVIRONMENT
SUBSTANCE

POLLUTANTS

ALLERGIC

DRUGS
Dust mites
Mold
Aspirin
NSAIDs (ibuprofen)Food
Animal dander
Pollen (plants, trees, flowers)

Smoke
Air Pollution
(cars, industry)
Perfume

Internal
Emotion
Stress

External
Humidity
Air Pressure Changes
Temperature Changes
Work
Exercise

Stimulates mast cells to release chemical mediators: histamine, serotonin, eosinophil, chemotactic factor of anaphylaxis [ECF-A], leukotrienes
Bronchoconstriction (bronchioles narrowed)
Bronchial edema
Increased bronchial secretions

Reactive airway disease RAD is a cause of asthma resulting from sensitivity

stimulation from allergens, dust, temperature changes, and cigarette
smoking.
Sympathomimetics: Alpha- and Beta2-Adrenergic Agonists
Increase cAMP causing dilation of bronchioles.
Epinephrine (Adrenalin) non selective sympathomimetic which is an alpha 1,
beta1, and beta2 agonists, administered in emergency situations to restore
circulation and increase airway patency.

Albuterol

(Proventil, Ventolin) is a selective beta 2 adrenergic drug that is effective for

treatment and control of asthma by causing bronchodilation with long
duration of action.
High doses of these drugs may cause some degree of beta 1 response such as
nervousness, tremors, and increased PR.

Metaproterenol

Second beta-adrenergic agent which was first marketed in 1961.

It has some beta1 effect but is primarily used as beta 2 agent.
It can be administered PO or by inhalation with a metered-dose inhaler or a
nebulizer.
The onset of action of the drug is 1 minute by inhalation and 15 min by PO.

Pharmacokinetics

Well absorbed in the GI tract. PB and t1/2 are UK. Metabolized by the liver,
excreted in the urine.

Pharmacodynamics

reverses bronchospasm by relaxing bronchial smooth muscle.

Promotes bronchodilation and increase cAMP.
Onset of action for oral and inhalation is fast, and its duration is short.
Excessive use of the drug by inhalation may cause tolerance and paradoxic
bronchoconstriction.
Can cause tremor, nervousness, heart palpitations and increased HR when
taken in large doses.
When taken with beta-adrenergic blocker, its effects are decreased.
Other sympathomimetic agents increase its effect.

Isoproterenol

(Isuprel) was the first beta-adrenergic agent used for bronchospasm,

introduced in 1941.

A non selective beta agonist. Because the beta 1 receptors are stimulated, the
HR increases and tachycardia may result. Beta2 stimulation promotes
bronchodilation.
Administered by inhalation using an aerosol inhaler or nebulizer, or IV for
severe asthmatic attacks.
Duration of action is short.
Because of its severe side effects from beta1 response, it is seldom
prescribed.
Use of an Aerosol Inhaler
It the beta2 agonist is given by a metered-dose inhaler (MDI) or dry powdered
inhaler (DPI), correct use of the inhaler and dosage intervals need to be
explained to the client.
If the client does not receive effective relief from the inhaler, either the
technique is faulty or the canister is empty.
If client does not use the inhaler properly to deliver the drug dose, the
medication may be trapped in the upper airways.
Because of drug inhalation, mouth dryness and throat irritation could result.
Excessive use can lead to tolerance and loss of drug effectiveness.
Bronchoconstriction develops with repeated, excessive use of
sympathomimetic oral inhalation. Frequent dosing can cause tremors,
nervousness, and increased HR.

Side Effects and Adverse Reactions

Side effects and adverse reactions of epinephrine include tremors, dizziness,

HTN, tachycardia, heart palpitations, cardiac dysrhythmias, and angina. Client
receiving this needs to be closely monitored.
Side effects associated with beta2-adrenergic drugs (e.g. albuterol,
terbutaline) include tremors, headaches, nervousness, increased PR, and
palpitations (high doses).
Beta2 agonists may increase blood glucose levels. Side effects may diminish
after a week or longer.
Bronchodilating effects may decrease with continued use. Dose may need to
be increased when tolerance to these drugs develop.
Anticholinergics
Ipatropium bromide (Atrovent), a new anticholinergic drug, used to treat
asthmatic conditions by dilating the bronchioles.
Unlike other anticholinergics, ipratropium has few systemic effects. It is
administered by aerosol.
When using the anticholinergic agent in conjunction with an inhaled
glucocorticoid (steroid) or cromolyn, the ipratropium should be used 5 min
before the steroid or cromolyn. This causes the bronchioles to dilate so the
steroid or cromolyn can be deposited in the bronchioles.

Ipratropium bromide with albuterol sulfate (Combivent) is used to treat

chronic bronchitis.
The combination is more effective and has a longer duration of action than if
either agent is used alone.
Methylxanthine (Xanthine) Derivatives
The second major group of bronchodilators used to treat asthma, which
include aminophylline, theophylline, and caffeine.
Stimulate the CNS and respiration, dilate coronary and pulmonary vessels,
and cause diuresis.
Theophylline
Aminophylline, the first theophylline preparation, was produced in 1936.
Relaxes the smooth muscles of the bronchi, bronchioles, and pulmonary
blood vessels by inhibiting the enzyme phosphodiesterase, resulting in an
increase in cAMP, which promotes vasodilation.
Toxicity is likely to occur when the serum level is >20mcg/mL, so the serum
or plasma concentration should frequently be monitored.
Theophylline use has declined sharply because of its potential danger of
serious adverse effects (e.g. dysrhythmias, convulsions, cardiorespiratory
collapse) and its efficacy has not been found to be greater than beta agonists
or glucocorticoids.
It is prescribed mostly for maintenance therapy in clients with chronic stable
asthma and other COPDs.

Pharmacokinetics

Well absorbed PO, but absorption may vary according to the specific dosage
form.
Food and antacids may decrease the rate but not the extent of absorption.
Dose size can also affect the rate of absorption: larger doses are absorbed
more slowly.
Metabolized by the liver, 90% is excreted by the kidneys.
Tobacco smoking increases metabolism of theophylline drugs, thereby
decreasing its t1/2.

Pharmacodynamics

Increases the level of cAMP, resulting in bronchodilation.

The average onset of action for oral theophylline preparations is 30mins; for
sustained-release cap., it is 1 to 2 hours. The duration of action for the
sustained-release form is 8 to 24 hours and approx. 6 hours for other oral and
IV theophylline preparations.

Side Effects and Adverse Reactions

Side effects and adverse reactions include anorexia, nausea and vomiting,
gastric pain, caused by increased gastric acid secretion, intestinal bleeding,
nervousness, dizziness, headache, irritability, dysrhythmias, tachycardia,
palpitations, marked HTN, hyperreflexia and seizures. Adverse CNS reactions
are more often severe in children than in adults.
To decrease the potential for side effects, clients should not take other
xanthines while taking theophylline.
Because of the diuretic effect of xanthines, incldg. Theophylline, clients
increase OFI and should avoid caffeinated products (e.g. coffee, tea,
chocolates, colas).
To avoid severe adverse effects, IV administration MUST be administered
slowly via an infusion pump.

Drug Interactions

Beta-blockers, cimetidine (Tagamet), propranolol (Inderal), and erythromycin

decrease the liver metabolism rate and increase the half-life and effects of
theophylline; barbiturate and carbamazepine decrease its effects.
Theophylline increases the risk of digitalis toxicity and decreases the effects
of lithium.
Phenytoin decreases theophylline levels.
If theophylline and a beta-adrenergic agonist are given together, a synergistic
effect can occur; cardiac dysrhythmias may result.