12/3/18

Functions:
¨ Brings oxygen into the
body
¨ Allows for exchange
of gases
¨ Leads to expulsion of
carbon dioxide and
DRUGS ACTING ON THE other waste products

RESPIRATORY SYSTEM
By: April G. Marqueses-Obon, RN, MSN

UPPER RESPIRATORY TRACT

Structure and function of the
respiratory system
¨ Nose
¨ Mouth
¨ Pharynx
¨ Larynx
¨ Trachea

Pairs of SINUSES PHARYNX and LARYNX

¨ Mucus produced on the sinuses drains into the nasal
cavity.
¨ From there, the mucus drains into the throat and is
swallowed into the gastrointestinal tract, where ¨ Larynx contains the
stomach acid destroys foreign materials. vocal cords and
epiglottis

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TRACHEA
¨ Trachea – the main
conducting airway into the
lungs.
¨ All of these tubes contain
mucus-producing goblet
cells and cilia to entrap
any particles that may
have escaped the upper
protective mechanisms.
¨ The walls of the trachea
and conducting bronchi
are highly sensitive to
irritation.
MACROPHAGE
¨ Mast cells are present
in abundance and
release of histamine,
serotonin, adenosine
triphosphate (ATP),
and other chemicals to
ensure rapid and
intense inflammatory
reaction to any cell
injury. BRONCHIAL TUBES composed of 3 layers:
cartilage, muscles and epithelial cells
GAS EXCHANGE
¨ Occurs in the alveoli
¨ Respiration
¤ The exchange of gases
at the alveolar level
¨ The sac is able to stay
open because of the
surface tension of the
cells is decreased by
lipoprotein
surfactant.
12/3/18
Receptors in the walls Receptors in the walls
of trachea are
stimulated
in the nasal cavity are
stimulated
A central nervous A central nervous
system is initiated system is initiated
COUGH SNEEZE REFLEX
Causes air to be pushed Forces foreign materials
through the bronchial tree directly out or the system,
under tremendous pressure opening it for more efficient
flow of gas
Cleaning out the foreign
irritant
LOWER RESPIRATORY TRACT
¨ Bronchial tree
¨ Smallest brochioles
¨ Alveoli
RESPIRATION
(the act of breathing to allow gas exchange)
¨ Inspiratory muscles
¤ Diaphragm, external intercostals, and abdominal muscles
¨ Vagus nerve
¤ A predominantly parasympathetic nerve, plays a key role in
stimulating diaphragm contraction and inspiration
¨ Sympathetic system
¤ Stimulation can lead to increased rate and depth of
respiration and dilation of the bronchi to allow freer flow of
air in the system
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SUMMARY:
¨ Respiratory system has two parts: upper and lower
respiratory tract. Gas exchanges occur in the alveoli. Respiratory Pathophysiology
¨ Nasal hairs, mucus-producing goblet cells, cilia, the
superficial blood supply of the upper tract, and the
cough and sneeze reflexes all work to keep foreign
substances from entering the lower respiratory
tract.
¨ Alveoli produce surfactant, which reduces surface
tension, among other functions.
¨ Medulla controls respiration, which depends on a
functioning muscular and a balance between the
sympathetic and parasympathetic systems.

1. Common Cold
¨ A number of viruses causes common cold. Mucus
Upper Respiratory Tract Conditions membranes become engorged with blood, tissues
swells, and the goblets cells increase the production
of mucus
¨ Sinus pain, nasal congestion, runny nose, sneezing,
watery eyes, scratchy throat, and headache.
¨ Blocks the outlet of the eustachian tube
¤ Feelingsof ear stuffiness and pain, more likely to
develop ear infection (otitis media)

2. Seasonal/Allergic Rhinitis 3. Sinusitis

¨ Inflammation of the nasal cavity, commonly called ¨ Occurs when the epithelial lining of the sinus cavities
hay fever. becomes inflamed.
¨ Specific antigen (e.g. pollen, mold, dust) ¨ Severe pain
¨ nasal congestion, sneezing, stuffiness, and watery
eyes

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4. Pharyngitis and Laryngitis

¨ Infections of the pharynx and the larynx Drugs acting on the upper
¨ Common bacteria or viruses respiratory tract
¨ Frequently seen in influenza
¨ Fever, muscle aches and pains, and malaise

A. Antihistamines First-generation (drowsiness) Second-generation (less sedating)

¨ dipenhydramine loratidine (Claritin)

¨ Block the release or action of histamine, a chemical (Benadryl)
¨

released during inflammation that increases ¨ promethazine ¨ cetirizine (Zyrtec)

secretions and narrows airways. (Phenergan) ¨ desloratadine
¤ H1 receptor – when stimulated extravascular muscles, ¨ brompheniramine (Bidhist) (Clarinex)
including those lining the nasal cavity, are constricted ¨ buclizine (Bucladin-S)
¨ azelastine (Astelin)
¤ H2 receptor – when stimulated, an increase in gastric
¨ cabinoxamine (Histex,
Palgic) ¨ fexofenadine (Allegra)
secretions occurs, which is a cause of PUD
¨ chlorpheneramine (Aller- ¨ levoceticizine (Xyzal)
¨ Designed to relieve respiratory symptoms and to Chlor)
treat allergies ¨ clemastine (Tavist)
¨ (p. 576)

Therapeutic Actions and Indications Pharmacokinetics

¨ Block the effects of histamine at the histamine-1
receptor sites, decreasing the allergic response.
¨ They also have anticholinergic (atropine-like) and
antipruritic effects.
¨ Seasonal and perennial allergic rhinitis, allergic
conjunctivitis, uncomplicated urticaria, and
angioedema
¨ Allergic reactions to blood or blood products and
¨ Well absorbed orally, with an onset of 1 – 3 hours
¨ Metabolized in the liver, with excretion in feces and
urine
¨ Cross the placenta and enter breast milk
NURSING CONSIDERATION:
• Administer drug on an EMPTY
STOMACH, 1 hour before or 2 hours
after meals; may be with meals if GI
upset is a problem

adjunctive therapy in anaphylactic reactions

4

Contraindications and Cautions
¨ Pregnancy and lactation
¨ Caution with renal and hepatic impairment
¨ Special care should be taken when these drugs are
used by any patient with a history of arrhythmias or
prolonged QT intervals
NURSING CONSIDERATION:
• Assessment
Other Nursing Considerations
¨ Note that patient may have poor response to one
of these agents but a very effective response to
another; the prescriber may need to try several
different agents to find the one that is most
effective
¨ Caution the patient to avoid excessive dose and to
check OTC drugs for the presence of antihistamines.
1. Nasal and Systemic
Decongestants
12/3/18
Adverse Effects
NURSING CONSIDERATION:
• Provide safety measures as
¨ Drowsiness and sedation appropriate if CNS effects occur
• Caution the patient to avoid alcohol
while taking these drugs.
¨ Drying of the respiratory and GI mucous
membranes, GI upset and nausea, arrhythmias,
dysuria, urinary hesitancy, and skin eruption and
itching associated with dryness
NURSING CONSIDERATIONS:
• Patient may experience dry mouth, which may lead to
nausea and anorexia; suggest sugarless candies or
lozenges.
• Increase humidity and push fluids.
• Have the patient void before each dose
• Provide skin care as needed.
B. Decongestants
¨ Decrease the overproduction of secretions by
causing local vasoconstriction to the upper
respiratory tract.
¨ Rebound congestion technically called, rhinitis
medicamentosa
¤ Reflex reaction to vasoconstriction is a rebound
vasodilation, which leads to prolonged overuse of
decongestants
Nasal Decongestants
(sympathomimetic amines)
¨ Stimulate the alpha-adrenergic receptors,
producing vascular constriction (vasoconstriction) of
the capillaries within the nasal mucosa.
¨ Shrinking of the nasal mucous membranes and
reduction in fluid secretion (runny nose).
¨ Nasal Spray or drops or in tablet, capsule, or liquid
form.
¨ Act promptly and cause fewer side effects
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Systemic Decongestants Systemic and Nasal Decongestants

(alpha-adrenergic agonists)

¨ Available in tablet, capsule, and liquid form and ¨ ephedrine HCl

are used primarily in allergic rhinitis, including hay ¨ naphazoline HCl
fever and acute coryza (profuse nasal discharge). ¨ oxymetazoline HCl
¨ Relieve nasal congestion for a longer period than
¨ penylephrine
nasal decocngestants; however, currently there are
¨ psseudoephidrine
long-acting decongestants.
¨ tetrahydrozoline

Side Effects and Adverse Effects Drug Interactions

¨ Jittery, nervous or restless (may decrease or ¨ Pseudoephedrine – decrease the effect of beta
disappear as the body adjusts to the drug) blockers
¨ Use of nasal decongestants for as little as 3 days ¨ Taken together with MAOI’s (monoamine oxidase
could result to rebound nasal congestion. inhibitors), decongestants may increase the
¨ Blood pressure and blood glucose level can possibility of hypertension or cardiac dysrhythmias.
increase NURSING CONSIDERATION: ¨ Avoid large amounts of caffeine – it can cause
• Contraindicated or used in increase restlessness and palpitations.
with extreme caution in
patients with hypertension,
cardiac disease,
hyperthyroidism, and
diabetes mellitus.

Intranasal Glucocorticoids or steroids

¨ Effective for treating allergic rhinitis.

2. Intranasal Glucocorticoids ¨ Anti-inflammatory actions
¨ May be used alone or in combination with an H1
antihistamine.
¨ Continuous use, dryness of the nasal mucosa may occur.
¨ Should not be used for longer than 30 days.
¨ Most allergic rhinitis is seasonal; therefore the drugs
are for short term use unless otherwise indicated by the
health care provider.

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Intranasal Glucocorticoids C. Antitussives

¨ Beclomethasone ¨ Drugs that suppress the cough reflex
¨ Budesonide ¨ Common cold, sinusitis, pharyngitis, and pneumonia,
¨ Dexamethasone are accompanied by an uncomfortable,
unproductive cough
¨ Flunisolide
¨ Fluticasone
¨ Triamcinolone

Drug Names
Pharmacokinetics
Therapeutic Actions and Indications
¨ Dextromethorphan, Codeine, Hydrocodone ¨ Rapidly absorbed and metabolized in the liver, and
(Hycodan) excreted in the urine. They cross the placenta and
¤ Act directly on the medullary cough center of the brain enter the breast milk NURSING CONSIDERATION:
to depress the cough reflex This drugs should not be used during
pregnancy and lactation
¨ Benzonatate (Tessalon)
¤ Acts as a local anesthetic on the respiratory passages,
lungs, and pleurae, blocking the effectiveness of the
stretch receptors that stimulate the cough reflex

Contraindications and Cautions

¨ Contraindicated to patients who need to cough to ¨ Caution should also be used in patients who are
maintain the airway (e.g. postoperative patients hypertensive to or have history of addiction to
and those who have undergone abdominal and narcotics (codeine and hydrocodone)
thoracic surgery) ¨ Patients who need to drive or to be alert should use
¨ Careful use for patients with asthma and codeine, hydrocodone, and dextromethorphan with
emphysema NURSING CONSIDERATIONS: extreme caution
• Assessment
• Ensure that the drug is not taken any
longer than recommended.
• Arrange for further medical
evaluation for coughs that persist or
are accompanied by high fever,
rash, or excessive secretions

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Adverse Effects Drug-Drug Interactions

¨ Drying effect on the mucus membranes and can ¨ Dextromethorphan should not be used with
increase the viscosity of respiratory tract secretions. monoamine oxidase (MAO) inhibitors
¤ Can lead to nausea, constipation, dry mouth ¤ hypotension, fever, nausea, myoclonic jerks, and coma
NURSING CONSIDERATION: could occur
• Provide other measures to help relieve
cough (e.g. humidity, cool temperatures,
fluids, use of topical lozenges)

¨ CNS depression, drowsiness and sedation

¨ GI upset, headache, feelings of congestion, and
sometimes dizziness

D. Expectorants Therapeutic Actions and Indications

¨ Enhances the output of respiratory tract fluids by

¨ Increase productive cough to clear the airways.
reducing the adhesiveness and surface tension of
¨ They liquefy lower respiratory tract secretions, these fluids, allowing easier movement of the less
reducing viscosity of these secretions and making it viscous secretions.
easier for the patient to cough them up.
¨ The result of this thinning of secretions is a more
¨ Available in OTC preparations
productive cough and thus decreased
¨ guaifenesin (Mucinex, Robitussin)
frequency of coughing.

Pharmacokinetics Contraindications

¨ Rapidly absorbed with an onset of 30 minutes and ¨ The drug should not be used in patients with a
a duration of 4 to 6 hours known allergy to the drug.
¨ Sites of metabolism and excretion have not been ¨ Pregnancy and lactation
reported. ¨ Persistent coughs

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Adverse Effects E. Mucolytics

¨ GI symptoms: nausea, vomiting, anorexia
NURSING CONSIDERATION:
• Advise the patient to take small, frequent meals ¨ Increase or liquefy respiratory secretions to aid
¨ Headache, dizziness, or both; occasionally a mild the clearing of the airways in high-risk respiratory
rash develops NURSING CONSIDERATION: patients who are coughing up thick, tenacious
• Advise the patient to avoid driving or performing
dangerous tasks if dizziness and drowsiness occur secretions.
¨ Discover the cause of the underlying cough. ¨ COPD, cystic fibrosis, pneumonia, or tuberculosis
¨ Not be used more than 1 week ¨ acetylcysteine (Mucomyst)
NURSING CONSIDERATION: ¨ dornase alfa (Pulmozyme)
• Caution the patient not to use these drugs for longer than 1 week
and to seek medical attention if the cough persists after that time.
• Alert the patient that these drugs may be found in OTC preparations
and that care should be taken

Therapeutic Actions and Indications Pharmacokinetics

¨ acetylcysteine (Mucomyst)
¤ Affects the mucoproteins in the respiratory secretions by
splitting apart the bisulfide bonds that are responsible
for holding the mucus material together.
¨ dornase alfa (Pulmozyme)
¤ Prepared by recombinant DNA techniques that
selectively break down respiratory tract mucous by
separating extracellular DNA from proteins.
¨ Administered by nebulization or by direct
installation into the trachea via endotracheal tube
of tracheostomy.
¨ Acetylcysteine is metabolized in the liver and
excreted somewhat in urine.
¨ Dornase alfa has long duration of action, and its
fate in body is not known.

Contraindication and Cautions Adverse Effects

¨ Caution should be used in cases of acute

bronchospasm, peptic ulcer, and esophageal
varices. ¨ GI upset, stomatitis, rhinorrhea, bronchospasm, and
occasionally a rash.
¨ There are no data on the effects of drugs in
pregnancy and lactation

9

Nursing Considerations
¨ Assessment
¨ Avoid combining with other drugs in the nebulizer.
¨ Dilute concentrate with sterile water for injection
¨ Note that patients receiving acetylcysteine by face
mask should have the residue wiped off the
facemask and off their face with plain water .
Lower Respiratory Tract Conditions
2. Pneumonia
¨ Inflammation of the lungs caused either by bacterial
or viral invasion of the tissue or by aspiration of
foreign substances into the lower respiratory tract.
¨ DOB and fatigue, fever, noisy breath sounds, and
poor oxygenation
12/3/18
¨ Review use of he nebulizer with patients receiving
dornase alfa at home. Patients should be cautioned to
store the drug in the refrigerator, protected from light.
¨ Caution cystic fibrosis patients receiving dornase alfa
about the need to continue all therapies for all their
cystic fibrosis
¨ Provide thorough patient teaching, including the drug
name and prescribed dosage, measures to help avoid
adverse effects, warning sings, that may indicate
problems, and the need for periodic monitoring and
evaluation.
¨ Offer support and encouragement.
1. Atelectasis
¨ Collapse of once-expanded alveoli
¨ Most commonly occurs as a result of airway
blockage, which prevents air from entering the
alveoli, keeping the lung expanded.
¨ Crackles, dyspnea, fever, cough, hypoxia, and
changes in chest wall movement
¨ Treatment: clearing the airways, delivering oxygen,
and assisting ventilation
3. Bronchitis
¨ Occurs when bacteria, viruses, or foreign materials
infect the inner layer of the bronchi.
¨ Swelling, increased blood flow in that area, and
changes in capillary permeability
¨ Narrowed airway during inflammation
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4. Bronchiectasis
¨ Chronic disease that involves the bronchi and
bronchioles.
¨ Dilation of the bronchial tree and chronic infection
and inflammation of the bronchial passages
¨ Fever, malaise, myalgia, arthralgia, and a purulent,
productive cough
¨ Chronic Obstructive Pulmonary Disease (COPD)
¤ Permanent chronic obstruction of airways, often related
to cigarette smoking
¤ Emphysema: loss of elastic tissue of the lungs,
destruction of alveolar walls, and a resultant alveolar
hyperinflation with a tendency to collapse with
expiration
¤ Chronicbronchitis: permanent inflammation of the
airways with mucus secretion, edema, and poor
inflammatory defenses.
Drugs acting on the LOWER
respiratory tract
12/3/18
5. Obstructive Pulmonary Disease
¨ Asthma
¤ Reversiblebronchospasm, inflammation, and
hyperactive airways
¤ Allergens or nonellergic inhaled irritants or by factors
such as exercise and emotion.
¤ Trigger causes an immediate release of histamine,
which results in bronchospasm in about 10 minutes. The
later response (3 to 5 hours) is cytokine-mediated
inflammation, mucus production, and edema
contributing to obstruction.
¨ Cystic fibrosis
¤ Hereditary disease involving the exocrine glands of the
respiratory, gastrointestinal, and reproductive tracts
¤ Results in accumulation of copious amounts of very thick
secretions in the lungs
¨ Respiratory Distress Syndrome (RDS)
¤ Causes obstruction at the alveolar level
¤ Frequently seen in infants who are delivered before
their lungs have fully developed and while surfactant
levels are still very low.
¤ Treatment: instilling surfactant to prevent atelectasis
and to allow lungs to expand
A. Bronchodilators/Antiasthmatics
¨ Medications used to facilitate respirations by
dilating the airways.
¨ Asthma and COPD
¨ Administered orally and absorbed systemically
¨ Other medications are administered directly into the
airways by nebulizers
¤ Sympathomimetics
¤ Anticholinergics
¤ Xanthines
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1. Sympathomimetics Therapeutic Actions and Indication

¨ Drugs that mimic the effects of the sympathetic ¨ ẞ-2 receptors found in the
bronchi
nervous system (dilation of the bronchi with
¨ Effects of higher levels of
increased rate and depth of respiration). sympathomimetics
¨ albuterol (Proventil) ¤ Increased BP, increased HR,
vasoconstriction, and
¨ arformoterol (Brovana) decreased renal and GI
blood flow
¨ bitolterol (Tornalate)
¨ Epinephrine
¨ ephedrine (generic) ¤ Drug of choice for the
treatment of acute
¨ epinephrine (EpiPen) bronchospasm, including
¨ terbutaline (Brethaire) that caused by
anaphylaxis

Contraindications and Cautions Adverse Effects

¨ Contraindicated and should be used with caution, ¨ CNS stimulation, GI upset, cardiac arrhythmias,
depending on the severity of the underlying hypertension, bronchospasm, sweating, pallor, and
condition: flushing.
¤ Cardiac disease, vascular disease, arrhythmias,
diabetes, and hyperthyroidism
¨ Can be used during pregnancy and lactation ONLY
if the benefits to the mother clearly outweigh
potential risks to the fetus or neonate.

Drug-Drug Interactions Nursing Considerations

¨ Avoid combination of sympathomimetic
bronchodilators with general anesthetics
cyclopropane and halogenated hydrocarbons.
¨ Assessment
¨ Reassure patient that the drug of choice will vary
with each individual.
¨ Advise the patient to use the minimal amount
needed for the shortest period necessary.
¨ Teach patients who use one of these drugs for
exercise-induced asthma to use it 30 to 60 minutes
before exercising.
¨ Provide safety measures as needed.

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¨ Provide small, frequent meals and nutritional
consultation if GI effects interfere with eating
¨ Provide thorough patient teaching, including the
drug name and prescribed dosage, measures to
help avoid adverse effects, warning signs that may
indicate problems, and the need for periodic
monitoring and evaluation.
¨ Offer support and encouragement.
2. Anticholinergics
¨ ipratropium (Atrovent)
¨ tiotropium (Spiriva)
¨ These drugs are not as effective as the
sympathomimetics but can provide some relief to
those patients who cannot tolerate the other drugs

Therapeutic Actions and Indications Pharmacokinetics

¨ Used as ¨ Available in inhalation, using an inhaler device.
bronchodilators ¨ Ipratropium is also available as a nasal spray for
because of their effect seasonal rhinitis.
on the vagus nerve (to ¤ Onset of action – 15 minutes when inhaled
block or antagonize ¤ Peak – 1 to 2 hours
the action of the
¤ Duration – 3 to 4 hours
neurotransmitter
acetylcholine at
vagal-mediated
receptor sites)

Contraindications and Cautions Adverse Effects

¨ Narrow-angle glaucoma, bladder neck obstruction ¨ Dizziness, headache, fatigue, nervousness, dry
or prostatic hypertrophy, and conditions mouth, sore throat, palpitations, and urinary
aggravated by dry mouth or throat. retention
¨ Presence of known allergy to the drug or to soy
products or peanuts.
¨ Pregnancy and lactation

13

Nursing Considerations
¨ Ensure adequate hydration and provide environmental
controls, such as the use of a humidifier.
¨ Encourage patient to void before each dose of
medication.
¨ Provide safety measures if CNS effects occur.
¨ Provide small, frequent meals and sugarless lozenges.
¨ Advise the patient not to drive or use hazardous
machinery if nervousness, dizziness, and drowsiness
occur with this drug treatment.
3. Xanthines
¨ Including caffeine and theophylline, come from a
variety of naturally occurring sources.
¨ Xanthines used to treat respiratory disease include:
¤ aminophylline (Truphylline)
¤ caffeine (Caffedrine)
¤ dyphylline (Dilor)
¤ theophylline (Slo-Bid, Theo-Dur)
Pharmacokinetics
¨ Oral: Rapidly absorbed in the GI tract, reaching
peak levels within 2 hours.
¨ IV: peak effects within minutes
¨ Both are widely distributed and metabolized in the
liver and excreted in the urine.
¨ They cross the placenta and enter breast milk
12/3/18
¨ Provide thorough patient teaching, including the
drug name and prescribed dosage, measures to
help avoid adverse effects, warning signs that may
indicate problems, and the need for periodic
monitoring and evaluation.
¨ Review the use of the inhalator with the patient;
caution the patient not to exceed 12 inhalations in
24 hours.
¨ Offer support and encouragement.
Therapeutic Actions and Indications
¨ Have direct effect on smooth muscles of the
respiratory tract, both the bronchi and in the blood
vessels.
¨ Inhibit the release of slow-reacting substance of
anaphylaxis (SRSA) and histamine, decreasing the
bronchial swelling and narrowing.
¨ Unlabeled use:
¤ Stimulation of respirations in Cheyne-Stokes respiration
¤ Treatment of apnea and bradycardia in premature infants
Contraindications and Cautions
¨ Caution should be taken with any patient with GI
problems, coronary disease, respiratory dysfunction,
renal and hepatic disease, alcoholism, or
hyperthyroidism
¨ Parenteral drug should be switched to the oral form
ASAP.
¨ Pregnancy and lactation
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Adverse Effects Drug-Drug Interactions

¨ Theophylline levels in the blood (N = 10 to 20 ¨ Nicotene increases the metabolism of xanthines in

mcg/ml) the liver; xanthine dose must be increased in
n GI upset, nausea, irritability, and tachycardia to seizures,
patients who continue to smoke while using
brain damage, and even death xanthines.
¨ Extreme caution must be used if the patient decides
Serum Level (mcg/ml) Adverse Effects
≥20 Uncommon to decrease or discontinue smoking, because severe
>20-25 Nausea, vomiting, diarrhea, xanthine toxicity can occur.
insomnia, headache, irritability
>30-35 Hyperglycemia, hypotension,
cardiac arrhythmias,
tachycardia, seizures, brain
damage, death

Nursing Considerations B. Drugs Affecting Inflammation

¨ Administer drug with food or milk. ¨ To alter the inflammatory process that leads to
¨ Monitor patient response to the drug (e.g. relief, of swelling and further airway narrowing
respiratory difficulty, improved airflow).
¨ Provide comfort measures, including rest periods, quiet ¨ Leukotriene receptors
environment, dietary control of caffeine, and headache ¨ Inhaled steroids
therapy as needed.
¨ Provide periodic follow-up, including blood tests. ¨ Mast cell stabilizer
¨ Provide thorough patient teaching, including drug name
and prescribed dosage, measures to help avoid
adverse effects, warning signs that may indicate
problems, and the need for periodic monitoring and
evaluation.

1. Leukotriene Receptor Antagonist Therapeutic Actions and Indications

¨ Developed to act more specifically at the site of ¨ Block many of the signs and symptoms of asthma,
the problem. such as:
¨ zafirlukast (Accolate) – first drug of this class to be ¤ Neutrophil and eosinophil migration, Neutrophil and
developed monocyte aggregation, Leukocyte adhesion, Increased
capillary permeability, and Smooth muscle contraction
¨ montelukast (Singulair)
¤ These are the factors that contribute to the
¨ zileuton (Zyflo) inflammation, edema, mucus secretion, and
bronchoconstriction

15

Pharmacokinetics
¨ Given orally
¨ Rapidly absorbed in the GI tract
¨ Metabolized in the liver
¨ Cross the placenta and enter breast milk
¨ zafirlukast, montelukast – excreted in feces
¨ Zileuton – cleared through the liver
Adverse Effects
¨ Headache, dizziness, myalgia, nausea, diarrhea,
abdominal pain, elevated liver enzyme
concentrations, vomiting, generalized pain, and
fever.
Nursing Considerations
¨ Administer drug in an empty stomach, 1 hour
before or 2 hours after meals.
¨ Caution the patient that these drugs are not to be
used during an acute asthmatic attack or
bronchospasm.
¨ Caution the patient to take the drug continuously
and not to stop the medication during symptom-
free periods.
¨ Provide adequate safety measures if dizziness
occurs.
12/3/18
Contraindications and Cautions
¨ Should be given cautiously in patients with hepatic
or renal impairment
¨ Should be used in pregnancy only it the benefit to
the mother outweighs the potential risks to the fetus.
¨ Caution should be used during lactation
¨ Not indicated for the treatment of acute asthmatic
attacks
Drug-Drug Interactions
¨ Use caution if propanolol, theophylline, terfenadine,
or warfarin is taken with these drugs because
increased toxicity can occur.
¨ Combined with calcium channel blockers,
cyclosporine, or aspirin.
¨ Urge the patient to avoid OTC preparations
containing aspirin
¨ Provide patient thorough teaching.
¨ Offer support and encouragement.
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2. Inhaled Steroids Therapeutic Actions and Indications

¨ Found to be very effective treatment of ¨ Used to decrease inflammatory response in the

bronchospasm airway.
¨ beclomethasone (Beclovent) ¨ Increases air flow and facilitate respiration
¨ budesonide (Pulmicort) ¨ Two effects:
¨ ciclesonide (Alvesco) ¤ Decreased swelling associate with inflammation
¨ flucticasone (Flovent) ¤ Promotion of beta-adrenergic receptor activity

¨ triamcinolone (Azmacort)

Pharmacokinetics Contraindications and Cautions

¨ Rapidly absorbed from the respiratory tract, but
they take 2 to 3 weeks to reach effective levels.
¨ Metabolized in the liver and excreted in the urine.
¨ Crosses the placenta and enters the breast milk
¨ Not for emergency use and not for use during an
acute asthma attack or status asthmaticus
¨ Pregnancy and lactation
¨ Caution in any patient who has an active infection
of the respiratory system.

Adverse Effects Nursing Considerations

¨ Sore throat, hoarseness, coughing, dry mouth, and ¨ Assessment
pharyngeal and laryngeal fungal infections ¤ Acute asthmatic attacks and allergy to the drugs;
systemic infections, pregnancy and lactation
¤ Perform physical examination
¤ Assesstemperature
¤ Monitor BP, pulse, and auscultation

¤ Assess respirations and adventitious sounds

¤ Examine the nares

17

Implementation
¨ Do not administer the drug to treat an acute asthma
attack or status asthmaticus.
¨ Taper systemic steroids carefully during the transfer
to inhaled steroids.
¨ Have the patient use decongestant drops before
using the inhaled steroid.
¨ Have the patient rinse the mouth after using the
inhaler.
¨ Monitor the patient for any sign of respiratory
infection.
3. Mast Cell Stabilizer
¨ Prevents the release of inflammatory and
bronchoconstricting substances when the mast cells
are stimulated to release these substances because
irritation or the presence of an antigen.
¨ cromolyn (Nasalcrom) – the only drug still
available in this class.
Pharmacokinetics
¨ Inhaled from a capsule and may not reach its peak
effect for 1 week.
¨ Available as a nasal spray and as an ophthalmic
solution (little systemic absorption)
¨ Active in the lungs and most of the inhaled dose is
excreted during exhalation, or if swallowed,
excreted in urine and feces.
12/3/18
¨ Provide thorough patient teaching, including the
drug name and prescribed dosage, measures to
help avoid adverse effects, warning signs that may
indicate problems and the need for periodic
monitoring and evaluation.
¨ Instruct the patient to continue to take the drug.
¨ Offer support and encouragement.
Therapeutic Actions and Indications
¨ Treatment of asthma and allergies
¨ Works at the cellular level to inhibit the release of
histamine and inhibits the release of SRSA.
¨ Prevents the allergic asthmatic response when
respiratory tract is exposed to the offending
allergen.
¨ Seasonal allergic rhinitis and in an inhaled form for
the treatment of allergies.
Contraindications and Cautions
¨ Allergy to the drug
¨ Cannot be used in acute attack and patients need
to be instructed in this precaution.
¨ Pregnancy and lactation (reserved for those
situations when the benefit to the mother outweighs
any potential risk to the fetus and neonate)
¨ Not recommended for children younger than 2
years of age.
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Adverse Effects
¨ Swollen eyes, headache, dry mucosa, and nausea
¨ Careful patient management can help to make
drug-related discomfort tolerable.
¤ avoid dry and smoky environments, analgesics, use of
proper inhalation technique, use of a humidifier, and
pushing fluids as appropriate
C. Lung Surfactants
¨ Allows expansion of the alveoli for gas exchange.
¨ beractant (Survanta)
¨ calfactant (Infasurf)
¨ poractant (Curosurf) - newest
Pharmacokinetics
¨ Directly instilled in the trachea and begin to act
immediately on instillation.
¨ Metabolized in the lungs by normal surfactant
metabolic pathways.
¨ NO CONTRAINDICATIONS
12/3/18
Nursing Considerations
¨ Review administration with the patient periodically.
¨ Caution the patient not to discontinue use abruptly.
¨ Instruct the patient taking cromolyn that this drug cannot
be used during an acute attack.
¨ Caution the patient to continue taking this drug, even
during symptom-free periods.
¨ Advise patient not to wear soft contact lenses; if
cromolyn eye drops are used.
¨ Provide thorough patient teaching.
¨ Offer support and encouragement.
Therapeutic Actions and Indications
¨ Used to replace the surfactant that is missing in the
lungs of neonates with RDS
Adverse Effects
¨ Patent ductus arteriosus, braducardia, hypotension,
intraventricular hemorrhage, pnuemothorax,
pulmonary air leak, hyperbilirubinemia, and sepsis.
¨ These effects may be related to the immaturity of
the patient, the invasive procedures used, or
reactions to the lipoprotein.
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 12/3/18

Nursing Considerations
¨ Monitor the patient continuously during administration and
until stable
¨ Ensure proper placement of the endotracheal tube with
bilateral chest movement and lung sounds.
¨ Have staff view the manufacturer’s teaching video before
regular use.
¨ Suction infant immediately before administration, but do not
suction for 2 hours after administration unless clinically
necessary.
¨ Provide support and encouragement to parents of the
patient, explaining the use of the drug in the teaching
program.
¨ Continue supportive measures related to the immaturity of
the infant.

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