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Anti-inflammatories why do we use these?
the pathophysiology for asthma, chronic bronchitis, and allergic sinusitis are created by the same mechanism. Each cilia, whether in the nasal passage or the bronchi and bronchioles is attached to a goblet cell.
goblet cells have what 3 functions?
- to moisturize the air when we inhale, humidify by producing mucus
- to produce histamines, eosinophils, leukocytes, and leukotrienes to allergens and germs we inhale. i.e. smoke
- moisturize fine hairs known as cilia to keep inhaled particles from getting into our lungs through the nasal passage. the goblet cells produce mucous to catch these toxins prior to the lungs.
Pathophysiology of anti-inflammatories
when the cilia are damaged, or the goblet cells are over-producing mucous and leukotrienes, the next reflex of the lungs is an inflammatory response, which produces leukocytes. As the cells swell, become inflmaed, and produce too much mucous, this makes the airway smaller. The next response or reflex of the lungs is to bronchospasm and cough these toxins out of the airway.
What are the ways that these anti-inflmmatory medications are delivered?
- nebulizer: misted treatment that you inhale.
- inhalation with MDI's (metered dose inhalers)
- oral medications to either prevent or treat inflammation that already exists.
Glucocorticoids are a type of anti-inflammatory what are they?
steroids that suppress the inflammatory response.
glucocorticoids are used for:
prophylaxis and chronic inflammation (COPD)
adverse effects of glucocorticoids are:
- oral candidiasis
- dysphonia- hoarse voice
- long term therapy can cause thinning of the bones and adrenal insufficiency- suppressing the normal adrenalin secretion
- slowing the growth in children
nursing implications for glucocorticoids are:
- educate the client to rinse their mouth after using an inhaler or nebulizer
- if the inhaler is preventative teach the client to use it as ordered, usually bid
- if they are using a nasal spray, teach the client to use it aimed toward the side of the nasal passage not straight up, to get better effect on the cilia
- if the client is on high dose therapy, educate them to wean off their drugs slowly and not stop them suddenly so that the adrenal glands can start working again. If they stop suddenly they may have a rebound exacerbation of the inflammatory response.
types and dosages of glucocorticoids include:
- QVAR - beclamethasone inhaler bid
- Pulmicort- budenoside inhaler bid or "respules bid for nebulizer
- Aerobid - flunisolide inhalder bid
- Flovent - by inhaler or diskus bid
- asmacort- triamcinolone inhaler bid
- Nasacort- triamcinolone nasally bid
- Teach client to increase dose by 2 puffs or tid when they have a flare up.
The most common forms of leukotriene modifiers/inhibitors are:
- singulair (montelukast)- safest drug
- accolate (zafirlukast)
- intal (cromolyn)
pharmakinetics of leukotriene modifiers/inhalers are:
- kast = mast cell inhibitors - keep the cells from producing leukotrienes and histamines, preventing inflammation in the airways.
- These are only used for prevention, not for acute corticosteroids for better effect.
MAB at the end of a drug means
monoclonal antibody class
a drug in the mab class is
Xolair (omalizumab) - decreases IgE
antibodies produced in lungs and responsible for allergic reactions.
dosage form of monoclonal antibodies is
only sub-q. very expensive imuno-suppressant, about $1,000 a dose, once a month, used for severe asthma that doesn't respond to other therapies.
monoclonal antibodies are SEVERE
nursing education is very important regarding monoclonal antibodies what would you teach?
- client can become more vulnerable to bacterial infections, candidiasis, and accelerated growth of abnormal cells.
- TB and previous cancer diagnoses are contraindications to MAB's
bronchodilators come in what dosage forms?
- usually given orally or by inhalation as MDI's or nebulizers
- exception is epinephrine
the pharmacokinetics of broncodilators
bronchodilators have a benzene ring wihch stimulates the sympathetic B-2 receptors in the bronchial muscle cells, activating the "flight or fight" response
bronchodilators are used for
prevention of "athletic asthma" and treatment of acute inflammation, acute asthma attacks, and to prevent bronchospasms. Must be taken on a rigid schedule if used for prevention, as they only have a T1/2 of 2 hours
examples of bronchodilators are
- albuterol MDI
- ** albuterol liquid PO has a longer T1/2
Bronchodilators side effects include:
- increased heart rate
- anxiety or tremors
- "fight or flight" symptoms
bronchodilators (xanthines) occur
naturally as herbal salts in nature coffee beans, coca leaves
pharmacokinetics of brinchodilators - xanthines
- work by stimulating the sympathetic nervous receptors in smooth muscle. remember that not only the bronchials have these receptors but also the heart and bladder have smooth muscle.
- T1/2: 6 hours
- onset is rapid 15 minutes
- therapeutic index is narrow
examples of xanthines are
- theophylline (aminophylline)
- theodur- XR- time release PO
- forms: can be given PO, or rectally as maintenance
- give IV for severe respiratory failure
- dose: adult loading dose is 5mg/Kg IV or PO
- warnings: Drug levels must be monitored every day and 30 minutes after giving IV loading dose.
- Therapeutic dose: 10-15 mcg/ml
side effects of xanthines are:
- drug toxicity: nausea, vomiting, seizures, flushing, tachycardia, dysrythmias
- due to sympathetic stimulation: insomnia and irritability, uriniary frequency and dehydration, tachycardia and hypertension, rare: aminophylline : induced psychosis
nursing implications for xanthines are:
- monitor drug levels and assess for toxic side affects
- listen to lung sounds - still wheezing?
- monitor oxygen saturation, heart rate and blood pressure constantly if giving IV, patient needs to be on heart monitor
- hydration for bladder spasms and possible dehydration
- accurate intake and output
bronchodilaters- anticholinergics include:
- atrovent (Ipratopium) also in combivent
- spiriva (tiotropium) 24 hour inhaler
pharmakinetics of anticholinergics
- these drugd are anti-cholinergics which work by blocking the parasympathetic nervous system, thereby blocking brinchospasms. Atrovent is also used nasally to dry up excess mucous. ex allergic rhinitus.
- These drugs are typically used for COPD patients. By blocking the parasympathetic nervous system, they act on the unconcious act of bronchospasm. specially useful in combination with beta aderenergics because of their synergistic properties.
- Good for those who wheeze at the site of a nurse or doctor.
allergies are cause by
the stimulation of the goblet and mast cells due to routine or seasonal allergens, recognized by the bodys B-cells. Allergies can range from a runny nose, a cough, to an anaphylactic experience.
the pathophysiology of allergies is
the same as asthma. overstimulation of mucoid production, inflammation, and chronic congestion
H1 receptor agonists are
first line antihistamines
the oldest antihistamine is ____ which is also a _____ so it ______.
benadryl, also a anti-chollinergic so it has a drying effect and sedative effect.
H2 antagonists, like zantac, are ___ drugs but also work as ___.
GI drugs, mild antihistimines
second generation antihistamines have
second generation antihistamines include:
- oral medications:
- nasal sprays: usually one in each nostril every 5-6 hours
- topical singulair for the nose:
side effects of second generation antihistamines include:
nose bleed and headache
glucocorticoids are used
in nasal sprays and work to prevent allergic rhinitus but not for acute infections.
- beconase AQ (aqueous)
nursing implications for antihistamines and glucocorticoids are:
- clean the top of your inhaler weekly
- dont use if nasal drainage changes from clear to colored, steroids can enhance the growth of bacterium
- use twice a day as ordered, to prevent flare ups. if one type doesnt work another might.
antihistamine that is in a class all by itself as a leucotriene inhibitor
nasalcrom (cromolyn sodium)
nasalcrom side effects
- are less than other sprays.
- safe enough for 2 year olds.
- takes longer to work. up to 2 weeks.
D is the intial used with a combination of what
antihistamines and decongestants.
decongestants work by
stimulating the symathetic blood vessels and in the nares, causing constriction and shrinking the vessels.
decongestants are very effective in people who
- get a stuffy nose
- have polyps
- or deviated septums which swell and sinuses cant drain properly.
advantages to decongestants are
they can be used for allergies, common colds, and sinusitis infections
adverse side effects to decongestants are
- nervousness, insomnia
- "fight or flight"
decongestants are contraindicated in
people on anti-hypertensives = stroke
forms of decongestants available
- topical (nasally) work faster and the client can become dependent on them.
- oral forms: these are the basis of meth
examples of oral decongestants include
opiods in cough medicine include
main problem with opioid anti- tussives is
dependence on the medication
opioid anti-tussives work by
suppressing the CNS, cough relfex
non-opioid anti-tussives include
- dextromethorphan (benadryl)
- tessalon perles (tetracaine derivative)
non-opioid anti-tussives all have the same effect of
suppressing the cough mechanism, but in different ways. may also be slightly sedating.
mucolystics does ..
breaks up mucous
mucomyst or humibid (acetylcholine) is the only one that
interacts with the mucous to make it more watery.
mucomyst is delivered by
a nebulizer inhaler
side effects of mucomyst are
- tastes and smells like rotton eggs
mucomyst cannot be used on a client with
patient education for cold medications include:
- most OTC are antihistamines with or without decongestants.
- anlagesics with caffeine
- anti-tussives with or without antihistamines and decongenstants
- OTC drugs are not approved for childer under 2 years old and may be dangerous.
- when the cold is over the toothbrush needs to be disinfected or a new one bought.
- do not use antihistamines to sedate children
- if you are on other meds see your PCP first