comp 7

• *UPPER: nose, sinuses, mouth, pharynx, larynx, epiglottis, trachea
• *LOWER: bronchi, bronchioles, lungs, alveoli, chest wall
• *gas exchange occurs across the alveolar capillary membrane
• -surfactant

• *primary: gas exchange
• *air conduction
• *protect lungs
• *warms
• *filter
• *humidifies
• *acid and base balance

• *mucus
• *bronchspasms
• *cough
• *cilia
• *sneeze reflex
• *Chemical mediators:
•  -leukotrienes
•  -macrophages
•  -*mast cells (have histamine in them)
•  -Histamine (proinflammatory immediately makes worse)

(immunoglobulin)

• *cough
• *increased secretions
• *mucosal congestion
• *bronchospasms
• *edema of airway
• *inflammation
• *sneezing

• *infants are obligated nose breathers
• *sphenoidal sinuses immature
• *tonsillar tissue normally enlarged.
• *airways smaller in diameter, more easily  obstructed by mucus
• *less mudcle mass->increased use of smaller intercostals and diaphragms
• *less airway cartilage->trachea softer and can collapse readily

**infants/children more at risk for respiratory problems due to anatomic differences

• *infections are usually viral with no need for abx
• *acetaminophen or ibuprofen, NO ASPIRIN
• *saline nose drops/nasal spray or mist
• *parent teaching: use of dropper
• *no oral decongestants
• *guaifenesin loosens/thins secretions

• *increased rigidity of thorax
• *decrease elasticity
• *decreased cough efficiency
• *decreased number of functioning alveoli
• *decreased # of cilia & action
• *decreased # of macrophages ->ineffective immune response

• *inhalants: (topical-right to source, fewer systemic side effects)
•  metered-dose inhaler, powdered dose inhalers, nebulizers
• *sprays
• *oral
• *injections
• *IV
• *syrups
• *lozenges

• *inhale medicationswith the head tipped backward to open airway
• *try to hold your breath for at least 10 seconds
• *rinse your mouth after using an inhaler or nebulizer (to prevent thrush), particularly important with inhaled steroids (suppresses the immune response)
• * clean nebulizer tubing & mouthpieces with soap, water and white vinegar

Side effects from corticosteroid therapy can vary whether you've used corticosteroids short term or long term.  Side effects from short-term corticosteroid use include insomnia, agitation, euphoria, increased appetite.  More side effects are from long-term use than from short, and they include weight gain, ulcers, hypertension, hyperglycemia, edema and more.  If you plan to stop using cortiocsteroids, you must taper your use.  Get instructions from your doctor on exactly how to do this.  If you stop using them suddenly, you risk getting acute adrenal insufficiency syndrome, which can be fatal.

• *antihistamines (prevent histamine response- cold or allergy sx)
•  -first generation
•  -second generation
• *decongestants (shrink nasal mucus membranes reducing fluid secretion)
• *intranasal glucocorticoids
• *antitussives (act on cough control center to suppress cough)
• *expectorants (loosen bronchial secretions)

• *ACTION: competes with histamine for receptor sites preventing a histamine response reduces nasopharygeal secretions, itching, sneezing
• *USE: treat acute & allergic rhinitis, sleep aid, dry-dry-dry

*not good in elderly-sedation increase falls

• *first generations antihistamines (more effective but causes sedation)
•  -diphenhydramine (benedryl)
•  -clemastine (tavist)
•  -chlorpheniramine (chlor-trimeton)

• *Second generation antihistamines
•  -nonsedating antihistamines: little to no effect on sedation- all OTC now
•  - cetririzine (zyrtec)
•  -fexofenadine (allegra)
•  -loratadine (Claritin)

• *administration: oral, IV, IM
• *Interactions: increase CNS, depression with alcohol and other CNS depressants
• *avoid use of MAOIs
• *SE: drowsiness, dry mouth, dizziness, blurred vision, wheezing, photosensitivity, urinary retention, constipation, GI distress, blood dyscrasias
• *CAUTION: in elderly->urinary retention & dizziness, pt with asthma

*dry, dry, dry

• *potential SE: dry mouth & drowsiness
•  -suggest sugarless candy or gum as well as ice chips to relieve dry mouth
• *avoid operating motor vehicles if drowsiness occurs
• * avoid alcohol or other CNS suppressants
• *read OTC labels, many products contain antihistamine
• *use sun block
• *do not use if pregnant
• *use with caution for patients with asthma, BPH, pneu, bronchitis (makes harder to get mucus out)
• *give with food to decrease gi distress

• *dilation of nasal blood vessels
•  -due to infection, inflammation, allergy
• *transudation of fluid into tissue spaces
•  -leads to swelling nasal cavity

• *stimulate alpha adrenergic receptors
•  -produces nasal vascular vasoconstriction (inc BP, avoid with HTN)
•  -shrinks nasal mucous membranes
•  -reduces nasal secretion

• *oxymetazoline (afrin)
• *naphazoline (allerest)
• *pseudoephedrine (Sudafed)
•  -administration: nasal spray, nasal drops, tablet, capsule, liquid
•  -interacitons:
•   *Sudafed may decrease effect of betablockers
•   *may increase HTN, dysrhythmia with MAOIs
•   *my increase restlessness, palpitations, with caffeine

**rebound congestion

• *nervous, jittery, restless
• *Alpha-adrenergic effect (hypertension, tachycardia, hyperglycemia)
• *rebound nasal congestion-when given topically via nasal inhalation

• *may lead to tolerance
• *may lead to rebound nasal congestion
• *should no use longer than 5 days

• *Read OTC label
• *do not take drug longer than 5 days
• *lie down or hyperextend neck to instill
• *blow nose prior to instillation of nasal sprays or solutions

• *fluticasone (Flonase)
• *Triamcinolone (Nasacort)
•  -action: anti-inflammatory
•  -use: treat allergic rhinitis,
•           may be used alone or in combination with H1 histamines
•           dexamethasone should be used no longer than 30 days to avoid systemic effects (infections)

• *Narcotic: codeine-more effective but need prescription
• *Non-narcotic-Dextromthorphan (DM)
• *action: suppress cough reflex by acting on cough center in the medulla *for cough suppression of NONPRODUCTIVE cough
• *oral, throat sprays, gargles, lozenges
• *SE: nausea, DROWSINESS, inability to cough
• *additional SE narcotics: RESPIRATORY DEPRESSION,CONSTIPATION, dependence

**QUIETS COUGH- given at noc

• *do not drink fluids for 30 minutes after taking lozenges or chewable antitussives
• *don't mix with alcohol or other sedating medications
• *caution when driving care or operating machinery
• *prevent constipation with narcotics
• *not for long term use

• *action: to thin and liquefy secretions
• *oral
• *medications:guiafenesin (robitussin, humibid),iodinated glycerol
• *SE: minimal with guiafenesin (N&V)
• *NRSG Implications: encourage fluids to help thin secretions
•    

• *guiafenesin & codeine
•  *action: suppress cough reflex by acting on cough center in the medulla, reduce viscosity of tenacious secretions
•  *use: nonproductive, irritating cough
•  *SE: drowsiness, dizziness, nausea
•  **LOOK at BOTH meds SE 
•                                    

• _{*anti-inflammatory agents- to reduce airway inflammation}
• *forms: nasal sprays, inhalers, oral, IV
• *indication for use: asthma, COPD, sinusitis, allergic rhinitis
•  (reduce edema)

• *inhalants (nasal or oral)->fewer SE
•  -fluticasone (Flonase)
•  -beclomethasone (vanceril)
•  -flunisolide (aerobid)
•  -triamcinolone (Nasacort, azmacort)
•  -budesonide (rhinocort)
• *oral- prednisone
• *IV: methylprednisolone (solu-Medrol)- more potent

**sicker patient is the lower on the list for tx

• *local effects: throat irritation, cough
• *cardiac, fluid, electrolyte disturbances (High sodium & low potassium)
• *elevated blood sugar
• *MS: osteoporosis, retarded growth
• *CNS
• *GI: bleeding, increase appetite
•  *suppression of immune system (risk for fungal infection)

**higher doses more likely see SE

• *potential SE
• *steps for proper use of MDIs:
•  -shake canister well
•  -exhale 
•  -inhale slowly
•  -hold breathe for 10 seconds
•  -wait 3-5 minutes before next puff
•  -rinse mouth

**never ever give corticosteroid without food--gi issues

• *proper use of inhaler
• *do not stop the drug abruptly-taper off
• *take every dose
• *notify MD if taking other medications
• *avoid exposure to infections
• *take oral meds with meals
• *administer bronchodilator first
• *notify MD of any SE
• *daily calcium/vit D supplements
• *monitor blood sugars

*osteoporosis issues with long use

• *alpha and beta2, adrenergic agonists
• *anticholinergics
• *corticosteroids
• *xanthines
• *leukotriene receptor agonist
• *cromolyn/nedocromil
• *mucolytics

• *also called: beta agonists, adrenergics
• *Actions: stimulate the sympathetic NS receptors, relaxes bronchial smooth muscles, dilates bronchioles, imitates the effects of norepinephrine
• *indications: asthma, bronchitis, COPD
• *forms: injection, inhalant, aerosol
• *do not help with inflammation

• *epinephrine-alpha & beta
• *isoproterenol (Isuprel)- beta 1 & beta 2
• **albuterol (Proventil)- selective beta 2
• *pirbuterol (maxair)-selective beta 2
• *salmeterol (servent)-selective beta 2 (takes longer to work)
• *advair: salmeterol & fluticasone (corticosteroid)

• *decreases GI tone and motility
• **bronchodilation
• *increases blood flow in skeletal muscles
• *activates liver glycogenolysis- increases blood glucose

• *rapid heart rate
• *tremors
• *arrhythmias
• *palpitations
• *restlessness, agitation
• *insomnia
• **caution: cardiac problems, HTN, DM, seizure disorders, hyperthyroidism

• *SE
• *proper use of meter-dosed inhaler (MDI)
•  -decreased dyspnea in 1-2 minutes
•  -ALBUTEROL IS FOR RESCUE
•  -salmeterol for prophylaxis only
•  -how to know if canister is empty (shake or check if have number)

• *rapid dose inhalation
• *mouth tightly closed around mouthpiece
• *dose can be greater than with MDI
• *can be used for children <4 y/o
• *salmeterol & fluticasone: advair discus
• *tiotropium bromide (Spiriva) handihaler
• powdered capsule
• one inhalation (capsule)

• *actions: block the effects of acetylcholine at the PSNS receptors of the bronchial tree->prevents/reduses bronchoconstriction of smooth muscles of bronchus
• *indicated for: chronic bronchitis, COPD
• *form: inhalant
• -take longer to work
• -not a rescue med

*cough, nervousness, nausea, GI upset, HA, dizziness

*CAUTION: narrow angle glaucoma

• -ipratropium bromide (atrovent)
• -tiotropium bromide (Spiriva handihaler)
• -combination drug: ipratropium/albuterol (combivent)

• *do not swallow capsule
• *place capsule in center of chamber of handihaler
• *pierce capsule by pressing and releasing button on side of the device
• *keep capsule in blistercard until immediately before use
• *peel foil bac only to the "stop" line" in the blister pack

• *aminophylline (somophyllin), theophylline (theo-dur)
• *action: relaxes smooth muscle of bronchi, bronchioles increase cAMP promoting bronchodilation
• *use: maintenance therapy for chronic stable asthma, COPD
• *therapeutic range: 10-20mcg/ml (toxicity greater than 20)--narrow range

• *contraindications: seizures, cardiac, renal, or liver disorders
• *administration: oral, IV
• *SE: dysrhythmias, nervousness, irritablility, insomnia, dizziness, flushing, hypotension, seizures, GI distress, intestinal bleeding, hyperglycemia, tachycardia, palpitations, cardiorespiratory collapse
• *peds: immature liver, increased metabolism

• *take with food
• *theophylline blood levels
• *no OTC meds without telling MD
• *sustained release (SR) not to crush
• *avoid caffeine products

• *montelukast (singular)- chewable tabs
•   zafirlukast (accolade)
•   zileuton (zyflo)
• *action: reduce inflammatory process and decrease bronchoconstriction
• **USE: prophylactic and maintenance for chronic asthma
• **SE: dizziness, HA, GI distress, abnormal liver enzymes, nasal congestion, cough, pharyngitis (anti-inflammatory)

• *singulair with or without food
• *accolate 1 hr before, 2 hrs after meal
• *monitor liver enzymes
• *well tolerated
• *accolade interacts with theophylline

• *USE
•  -prophylactic treatment of bronchial asthma
•  -not to be used for acute asthmatic attack
• *ACTION:
•  -antiflammatory effect and suppresses the release of histamine
• *Administration:
•  -inhalation and oral (cromolyn)
• *SE:
•  -cough, bad taste
•  -cromolyn: rebound bronchospasm

• *action: liquefies and loosens thick mucus secrections
• *administration: administer 5 minutes aafter a bronchodilator, should not be mixed with other drugs
• *also an antidote for acetaminophen overdose if within 24 hrs
•  -give orally diluted in juice or soft drinks