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Upper respiratory disorders--- common cold acute rhinitis sinusitus acute pharyngitis

Common cold: Incidence is seasonally variable. Adults- 2-4 per year; Children- 4-12 per year Caused by: rhinovirus Incubation period: contagious 1-4 days prior to onset of symptoms and first 3 days of the cold. Symptoms: nasal congestion, nasal discharge, cough, increased muscosal secreations. Treatments: antihistamines, decongestants, antitussives, expectorants. Acute Rhinitus: Acute inflammation of nasal mucosa. Accompanies the common cold. Increased nasal secretions. Allergic Rhinitus: hay fever Cause by: pollen from foreign substances. Increased nasal secretions. Sinusitus: Inflammation of a sinus Treatment: systemic or nasal decongestants, fluids, antibiotics. Acute Pharyngitus: Caused by: virus or bacteria. Inflammation of throat (sore throat). Treatment: saline gargles, acetaminophen, antibiotics with bacterical infection.

Upper Respiratory drugs---Antihistamines: Histaminecauses vascular smooth muscle contraction= runny nose, congestion. Acts to prevent histamine response, decrease nasal pharyngeal secretions, nasal itching. Not to be used in emergencies. 2 types of antihistamines: o H1 blockers (antagonists): relax smooth muscle of nasal cavity. o H2 (antagonists): decrease gastric secretions. Used for peptic ulcer disease, not respiratory.

First generation Antihistamines: Side effects: drowsiness, anticholingeric effects (dry mouth, decreased secretions). EX: Benadryl Diphenydramine (Benadryl): o Treats rhinitis, common in ingredient in cold/allergy and sleep preparations. o Available OTC (oral and topical). o Should not be used as sleep meds for the eldery. o Has increased effect with CNS depressents. o Administered: orally, IM, IV. o Can be used to medicate before blood transfusions. Second generation antihistamines: Non-sedating, less cholingeric effects. EX: Zrytec, allegra, Claritin, alstelin (nose spray). Decongestants: congestion -(dilation of BV, swelling) caused by infection, inflammation, or allergy. Acts to stimulates alpha-adrengerigic receptors= vascular constriction of capillaries. Shrinks nasal mucous membranes, and decreases nasal fluid secretions.

Nasal decongestants: Administered: nasal spray, nasal drops, orally Rebound nasal congestion- (if taking for longer than 5 days) occurs with frequent use; Builds tolerance. Rebound vasodilation instead of constriction. Systemic decongestants: Works longer then nasal but have more side effects. Side effects: stimulation of CNS, Inceased BP, Increased HR, Increased glucose. Caution with: HTN, thyroid, cardiac disease. EX: ephedrine, phenylephrine, pseudoephedrine. Phenylpropanolamine: Used for cold remedies and weight loss. Removed by FDA because of cardiovascular problems. Intranasal Glucocorticoids: Steroids used to treat allergic rhinitus. Acts by decreasing local immuse response; decreased runny nose, sneezing, congestion. EX: Beconase, Vanceril, Flonase, Nasacort. Antitussives: Acts on cough center in medulla to suppress cough reflex. Used if cough is no productive and irritating. 3 types:

o Nonnarcotic: (OTC). EX: dextromethorphan, romilar, robatussin DM. o Narcotic: EX: codine o Combination: Most common Expectorants: To loosen bronchial secretions. Hydration is best expectorants. Questionable if clinically effective. Used in combination with anttissives, antihistamines, antocholinergics. EX: Guaifenesin Products (robatussin).

Lower Respiratory disorders--- Restrictive lung disease COPD o Asthma o Bronchial asthma o Acute asthma

Restrictive lung disease Decrease in total lung capacity. Loss of elasticity of the lung tissues or fluid accumulation. Decreased ability to take full inhalation Types and causes: Pulmonary fibrosis Pneumonitis Lung tumors Thoracic deformities (scoliosis) Myasthenia gravis COPD An airway obstruction with increased airway resistance to airflow out of the lung (exhale). Types and causes: Chronic bronchitis Bronchiectasis Empheseyma Chronic asthma Caused by: smoking, chronic lung infections, genetics. Symptoms: dsypnea, mucos secretions, bronchoconstriction. Permanent/ irreversible damage to lung tissue. Treatment: focused on symptom control Asthma Reverisible bronchospasm with no structural changes. Inflammed airway. Cause by: hyperactive immune system, stimulated by a trigger. Common triggers: infection, exercise, stress, genetics, allergies. Symptoms: wheezing, difficulty breathing, coughing, tightness in chest. Bronchial Asthma Allergens attach to mast calls and basophils to release chemical mediators.

Chemical mediators are responsible for bronchoconstriction. Allergens: environment, pollutant, allergic substance, drug.

Acute asthmatic attack If happens, goal is to stop bronchospasm, and to prevent the continued hyerimmune response.

Lower Respiratory drugs---Sympathomimetic Drugs- Increase CAMP in lung tissue resulting in bronchodilation. It restores circulation and increased airway patency. Dangerous to use except in life threatening situations. Side effects: heart palpaltations, HTN Used for: acute asthma attacks. EX: Isuprel, Alupent, Proventil Isoproterenol (Isuprel): Non-selective adrenergic agonist (beta1 and beta2) Effects: increased HR and bronchodilation. Administered: inhaler, nebulizer, IV Short action Rarely used because of severe side effects. Metaproterenol (Alupent): Selective adrengeric agonist (beta2 ..some beta1). Effects: bronchodilation, some increase HR (some tremors and nervousness). Administered: orally, inhalation. Used as maintenance for chronic asthma. Can lead to tolerance. Overuse can lead to paradoxical spasm. Albuterol (proventil): Selective adrengergic agonist (beta2). Effects: bronchodilation (increase HR, increase blood glucose). Administered: aerosol, MDI, dry powder discus. Preferred emergency treatment; rescue inhaler for home. Can lead to tolerance. Anticolinergic Drugs- Blocls cholingergic receptors in PNS. Stimulates the CNS and repiration, dilates coronary and pulmonary vessels, caused mild diueresis.

EX: Atrovent Ipratropium (Atrovent): Effects: bronchodilation. Administered: aerosol inhaler. If using B-agonist, used Atrovent second. If using corticosteroids, use Atrovent first. Combivent- combination drug. Atrovent and Albuterol. = increased effect, increased duration.

Methylzanthine (xanthine) derivative- Bronchodilator. Second major group. Inhibits phosphodiestrease--- increase CAMP---- cause broncodilation by relaxing smooth muscle. Stimulates CNS and respirations, dilates coronary and pulmonary BV, mild diuesis. EX: aminophylline, theophylline, caffeine. Theophylline Methylxanthine derivative. Effects: bronchdilation in acute attacks. Administered: IV, oral. Low therapeutic index, monitor drug levels closely. Side effects: GI disturbance, cardiac dysrrhythmias, hyperglycemia, diuretic effect, palpations,nervousness. Not frequently used. Tobacco increases metabolism therefore there would be less effect of drug. Leukotriene Receptor Antagonists/ inhibitors- Leukotrienes are mediators that enhance immune response. Reduce inflammation and decrease bronchoconstriction. Used for excerise-enduced asthma. NOT for acute asthma attacks. Effects last for 24 hours. EX: Singulair, Zyflo, Accolate. Glucocorticoids- Anti-inflammatory effect (decrease lymphocyte activity). Must taper dose when stopping. o Aerosol inhalerhas less systemic effects. Must rinse mouth and use spacer. EX: Vaneril, Beclovent. o Tablet--- used for maintainence. EX: Prednisone

o Injection--- for acute illness. EX: Decadron, Solu-merdrol Mass Cell Stabilizers Stablilizing mast call membranes to suppress the release of histaminereduced inflammation. Does not have bronchodilator effect Not for acute asthma attack. Must be taken daily. Side effects: cough, bad taste. EX: Intal, Tilade (taper Intal to prevent rebound bronchspasm) Mucolytics Liquifies and loosens thick mucous secretions. Smells and tastes awful. Administered: aerosoltake 5 minutes after bronchodilator. EX: Mucomyst o Orally, antidote for acetaminophen overdose. o Protect kidneys in radiology die studies.

Three main components of functional circulatory system: Effective pump (myocardial contractility). How strong/functioning muscle is. Vasomotor tone (peripheral vascular resistance PVR). Tightness of BV walls. Extracellular fluid volume (blood volume). Enough blood to deliver O2. Desired effects of cardiac drugs: Improve pump function (contractility and rate control). Decrease cardiac O2 requirements (rate control, modify preload, decrease afterload, contractility) Improve blood flow to tissues (increase cardiac output and decrease PVR).

Drugs used for hypotension/shock--Catecholamines Sypathomimetics both are vasopressors to increase tightness of BV

Alpha, beta adrengeric agonists- Increase: HR, contractility, vasomotor tone. EX: Epinephrine, dopamine, dobutamine. Epinephinrine: most powerful in increase HR, contractility and vasomotor tone. Increases O2 need by heart. Works fast. Dopamine: Low dose- improve renal flow High dose- Increase HR, BP; Acts similar to epiniephrine. Dobutamine: Low dose- increase heart contractility To treat CHF(doesnt affect rate as much as dopamine).

Drugs used to improve pump function/ treat CHF---Cardiac Glycosides- EX: Digitalis, digoxin, photophodiesterase Inhibitors Digoxin: Increase strength of contraction. Increase vagal tone (parasympathetic)

Decrease impulse velocity Postitve ianotrope Negative dronotrope Theraputic uses: improve heart funcation, cardiac output control, rate and rhythm control. Side effects: rhythm and rate issues, headache, nausea, vomiting, yellow vision, halo effect. Narrow therapeutic index: toxicity >2.0 mg/dlhighly protein bound. Check for: adequate urine output and weight loss due to fluid loss. Decreased edema. Check for hypokalemia because it increases action of Digoxin. Side effects: thrombocytopenia, decreased BP, dysrhymias.

Photphodiesterase Inhibitors: Used to treat CHF if digoxin is not effective. Positive ianotrope. Increases vasodilation. Decrease preload and after load. Watch for hypokalemia because it can increase effects. EX: Amrinone, primacor Primacor must be IV, used short term. Make sure to monitor rate and rhythm. Side effects: thrombocytopenia, decreased BP, dysrhythmias.

Drugs to treat angina---Angina- acute cardiac pain caused by inadequate blood flow to the myocardium. Types of drugs: Nitrates Beta-blockers Calcium channel blockers Purpose: maintain blood flow through coronary arteries (keep open) to relieve ischemic pain. Pain is caused by lack of O2 (blood flow) to myocardium tissues.

Types of angina: Chronic stable- predictable. Usual due to stress; Most common. Unstable- changing, inconsistent. Vasospastic- occurs at rest; Unpredictable Must have balance of O2 supply and demand to prevent angina.

Nitrates Acts to promote vasodilation. Effects both veins and arteries. (increase flow, decrease pressure) Administered: SL, IV, topical. Cannot be given orally- too much is loss with first pass. Side effects: hypotension, headache, (BV inside skull dilate). EX: Nitroglycerine (NTG) Nitroglycerine (NTG) Venous vasodilation- decreases preload. Less blood back to right side of heart. Arterial vasodilation- decreases afterload and increases flow through coronary arteries. Bigger vein to push into. Emergency use for angina. Has to tingle- do not take more than three tabs. Overall, decreased O2 demand and increased supply of O2 to heart. More blood gets directly to cardiac muscle. Beta blockers Decrease sympathetic effect. Used to treat many heart problems. Can increase excerise tolerance. Side effects: decrease BP, HR, sexual dysfunction, bronchospasm (nonselective), glucose control problems. All with increase HR and decrease O2 demand. Beta1 blockers are better. EX: Selective- atenolol, metoprolol. Nonselective- propanolol (inderal) Used if no respiratory problems. Must taper dose to prevent rebound angina or high BP. Calcium channel blockers Act to prevent movement of calcium across membrane so less muscle contracts. Arterial vasodilation. Negative inotrope. Negative dronotrope. Decreased O2 demand. Side effects: bradycardia, peripheral edema, hypotension, constipation, headache. May cause liver and renal changes. EX: Norvasc, verapamin, dilitazem. (dilate arteries, decrease contractility, HR, pressure)

Drugs to treat hypertension---HTN BP over 140/90 but intervention is required before that. Individualized treatment plan is complex and may require multiple drug types.

Monitor BP, HR, potassium levels, orthostatic changes. Do not stop abruptly. There are many factors to consider in how BP is controlled; So you need to be able to affect many mechanisms.

Type of drugs: Adrengeric agents Vasodilators ACE inhibitors ARIIBs Diuretics Adrengeric blockers CA channel blockers Adrenergic Agents Usually not the first choice but may be good in patients with: increased lipid levels. It can decrease LDL. 2 Types: Alpha 1 blocker: blocks receptors in peripheral nervous system to cause vasodilation. EX: prazosin (minipress) Alpha 2 agonists: stimulate alpha 2 receptors in CNS to cause vassdilation. EX: catapress, resperpine (decreases NE and serotonin in CNS). Vasodilators Acts directly on arterior smooth muscle to cause relaxation and vasodilation to decrease PVR (blood pressure). Afterload reducer Used for maintenance and emergency treatment. EX: apersoline, rogaine, nipride (used in ICU only). ACE Inhibitors Acts to prevent angiotensin I fron converting into angiotensinogen II. Used for CHF, renal protection for diabetes patients (protects kidneys). Decreases left ventricular hypertrophy after MI. Good for pt where heart failure problem is the pump. Side effects: hyperkalemia, cough, orthostatic hypotension, acute renal failure, renal insufficiency. Can cause angioedema- severe swelling of tongue and lips. Can occlude airway; it is an allergic reaction. EX: Captoen, prinivil, accupril

Renin/angeotension cycle Decreased BF, BP

Renin

angeotensin I

angeotensinogen II vasoconstrictor

ACE Inhibitors vasoconstriction and fluid Retention decreased

Aldosterone Sodium and h2o retention

ARIIBs Works at receptor. Blocks angiotensinogen II from binding to receptors. Prevents vasoconstriction, and aldosterone secretion (a-II still formed it just cannot bind to receptor). Used for CHF, HTN Side effects: upper respiratory infection, headache, angioedema Caution with: diebetics, renal impairment, heart failure EX: cozar, diovan

Diuretics Used to treat conditions that involve extra fluid volume in body: heart failure, renal disease, HTN. Decrease fluid volume by increase urine output. Dieresis- to produce increased urine flow. Nattriuresis- loss if Na (sodium) in urine. Blocking Na and h2o reabsorption= Na and H2o loss in urine= antihypertensive effect. Usually used in combination with other drugs (anti-hypertensives). Interventions: monitor fluid volume, daily weights (most effective), breath sounds, edema, BP, fatigue. Teaching: Orthostatic changes, diet (may need K), timing, self-monitoring. Labs: electrolyte imbalances, hyper/hypo-kalemia, hyper/hypo-calcemia. EKG changes, GI motility, muscle strength or weakness. o The more urine loss= the more electrolyte loss.

Types of diuretics: Thaizide or thaizide-like Loop or high ceiling Osmotic Carbonic anlydrase inhibitor Potassium-sparing Thiazide and thiazide-like Acts on the distal tubule to increase Na, Cl, h2o loss. Used for HTN, edema, CHF, cihrros Caution with: decreased renal function, steroids, digoxin (increased effect with hypokalemia). EX: hydrochorothaize (HCTZ). Loop diuretics Acts on ascending loop of henle. Inhibits Na reabsorption= water loss. High ceiling drug- as the dose increases, so does the effect. Administered: oral or IV. Associated with ototoxicity- hearing loss. Hypokalemia is a big problem (especially if on digoxin). EX: Lasix, bumex, edcrin (lasix tolerance) Osmotic diueretics Acts by increasing osmolarity of plasma and fluid (BV) in renal tubules.

Increased Na, Cl, K, h2o excretion. Used: in emergencies, short term o To decrease intracranial pressure- head injury o To increase h2o loss during hemodialysis. Side effects: fluid and electrolyte abnormalities, pulmonary edema, tachycardia, hypotension. EX: mannitol Give IV, watch for crystals, use filter.

Potassium-sparing diuretics Acts on collecting distal renal tubules. To promote Na, h2o excretion and K retention. Interferes with Na/K pumps that regulate aldosterone. (works directly against it). Side effects: hyperkalemia. Caution: with ACE inhibitors. EX: Aldacton

Drugs for circulatory disorders---Thrombus formation- formation of a clot in artery or vein. Clot formed in: Artery- blood flow inhibited= ischemia, necrosis. Happens due to platelet aggregation, atherosclerosis. Coronary artery- heart attack; head artery- stroke. Vein- decreased venous return, edema. Happens die to stasis, obesity, vessel injury, smoking, birth control. Types of drugs: Anticoagulants Antiplatelet drugs Thrombolytics Antilipemics Peripheral vasodilators Anticoagulants EX: heprin, Coumadin, direct thrombin inhibitors. Heparin Does not dissolve a clot. Prevents it from getting bigger. Inhibits thrombin (clotting factor) so fibrin is not formed. Short half-life (2-4 hours); for short term use. Administered: IV, SC Dose should be weight-based and determined by desired effect: o Very lose dose- used to keep central venous access lines open. o Low- given SC for prophylaxis of DVT. Available in several doses and concentrations. May be used as bridge for pt on Coumadin who has to have surgery. Side effects: bleeding, thrombocytopenia, HIT Labs to monitor: PT, APTTto make sure clotting time is longer than normal. Antidote: Protamine sulfate- IV LMWH (low molecular weight heparins)--Actions same as heparin. Longer half life (12-24 hours). Self injectable. At home use due to longer action. Can be used as bridge. Dose based on weight. EX: Lovenox, fragmin.

Warfarin (Coumadin) Acts by inhibiting Vitamin K clotting factors. Used for: prophylaxis if pt is a high risk of thrombus formation. Long term use for maintainence (months to years). Long half life/ highly protein bound. Side effects: bleeding. Its spontaneous and serious. Labs to monitor: PT, INR. Must be stopped 2-3 days before invasive procedures. Antidiote: o Immediate: fresh frozen plasma. o Slower: Vitamin K (SC or IV). Direct thrombin inhibitors Acts directly to prevent thrombin from converting fibrinogen to fibrin. Used if allergic to heparin. Administered: IV. EX: acova, refluden. Antiplatelet-- Acts on arteries to prevent platelet aggregation by preventing thrombosis. Used for: prophylaxis for CVA, MI EX: persantine, plavix Also used for emergency if actively forming clot in brain or heart. EX: ReoPro, Integrillin Given IV in ER or enroute. Asprin- Inhibits platelet aggregation. Low doses given for prophylaxis artery thrombosis. Thrombolytics (clot busters) Acts by increasing fibrinolytic action of converting plasminogen to plasma. Destroys fibrin= clot disintegration. Used for: acute MI, CVA, DVT, pulmonary embolism. Small dose- declot catheter and drainage tubes. Side effects: vascular collapse, hemmorage. EX: t-PA, activase, retavase, abbokinase. Antilipemics Acts to lower blood lipid levels. Used for: decreasing cholesterol (>240 is high risk). Decreases LDL, VDL, increases HDL.

EX: stains/vastains, fibric acid derivatives, nicotinic acid, azetidinone, resin. Stains/vastains (HMG CoA inhibitors)--- Acts to interfere with how lipids and lipoproteins are metabolized and formed in the liver. Blocks HMG CoA which forms lipoproteins. Monitor liver function. Side effects: myopathies (disease in muscle), rhabdomyolysis (break down of protein in skeletal muscle).

Examples of other antilipemics Fibrinic acid derivatives- dangerous. Nicotinic acid (niacin, Vit B2)- not tolerated well, severe flushing. 2 Azetidinone- inhibits absorption of cholesterol from small intestine. Side effects: diaherria. Best in combination with stain drugs. Resin (questran) Works in gut to collect cholesterol. Sticky. Combines cholesterol and bile acid to be excreted. Do not give with other meds because it prevents absorption. o 1 hr before; 4 hrs after. Peripheral Vasodilators-- Acts to increase blood flow in extremedies. Used for: pts with hyperlipidemia, atherosclerosis, vasospasm, PVD, raynauds. 2 types: Adrenergic agonists- EX: alpha: minipress. EX: beta: vasodilan used for tiny vessels in hands and feet. Direct-acting peripheral vasodilator EX: pavabid.

Other drugs to improve flow---Hemorrheolgic-- Acts by improving microcirculation and decreasing blood viscosity and decreasing flexibility of RBC. Used for: intermittent claudication. Side effects: flushing, sedation, GI disruption, No smokingbiggest risk factor for peripheral artery disease. EX: trental

Viagra Acts as vasodilator to increase blood flow. May be used for pulmonary HTN. Caution: talking with nitrates (increase BP, can go blind). Associated with transient ischemic attack.