Respiratory agents- DRUGS OF RESPIRATORY SYSTEM

RESPIRATORY AGENTS
MATHEW VARGHESE V
MSN(RAK),FHNP (CMC Vellore),CPEPC
Nursing officer
AIIMS Delhi
1
mathewvmaths@yahoo.co.in

INTRODUCTION
 Respiratory agents is a term used to describe a
wide variety of medicines used to relieve, treat, or
prevent respiratory diseases such
as asthma, chronic bronchitis, chronic
obstructive pulmonary disease (COPD),
or pneumonia.
 Respiratory agents are available in many different
forms, such as oral tablets, oral liquids, injections or
inhalations.
2

RESPIRATORY AGENTS
Anti Asthmatic drugs
Muco active Agents
Drugs for Cough
*Antibiotics
*ATT 3

ANTI-ASTHMATIC DRUGS
Definition: Drugs used to treat bronchial asthma
Bronchodialtors
Antiinflammatory Drugs
Antihistamines
Leukotiene inhibitors
Anti IgE drugs
4

BRONCHODILATORS
Beta Adrenergic
Agonist or
sympathomimetics.
Methylxanthines
5

Beta Adrenergic Agonist or
sympathomimetics.
 Non selective beta adrenergic agonist :
 Epinephrine
 Ephedrine
 Isoproterenol
 Selective beta adrenergic drugs:
 Albuterol
 Terbutaline
 Metaproterenol
 Pirbuterol
 Bitolterol
 Salmotero
 Formoterol
6

EPINEPHRINE:
 It stimulates alpha and beta1as well as beta2
receptors.
 It is an effective rapid acting bronchodilator when
injected S/C (0.4 mL of 1:1000 solution) or inhaled
as a microaerosol from a pressurised canister (320
mcg/ puff).
 Adverse effects
 Tachycardia,
 Arrythmias
 Worsening of angina pectoris.
7

EPHEDRINE:
 Used in asthma for longest time.
 Longer duration and lower potency than
epinephrine.
 Not much used nowadays due to development of
β2- selective agents.
8

ISOPROTERENOL:
 A potent bronchodilator , producing effect in 5
minutes.
 Duration of action 60-90 minutes.
 High doses associated with cardiac arrhythmias
leading to death.
9

SELECTIVE BETA ADRENERGIC DRUGS:
 Mechanism of action: They causes widening of
the airway by relaxing bronchial smooth muscles by
stimulate beta receptors.
10

EXAMPLES
11

 Indications/uses
 Relieving the distress of asthma.
 Bronchospasm or bronchoconstriction.
 Contraindications/ Precautions.
 Patient with uncontrolled arrythmias.
 Prolonged use of albuterol may cause hypokalemia
12

ADVERSE EFFECTS
 Nervousness.
 Anxiety.
 Tremor.
 Headache.
 Palpitations.
 Tachycardia.
 Arrhythmias.
13

 Drug interactions
 (Beta) blocker antagonize the effects of adrenergic
agonists.
 Prolonged use of theophylline cause additive
effects.
 Nursing Responsibilities
 Nurse should monitor the patient’s blood pressure,
pulse, respiratory rate, and breathing sounds.
 Teach the patients that how to use inhalers.
 Instruct the patient to avoid respiratory irritants,
such as smoke, dust, and strong smell.

14

BRONCHODILATORS: METHYLXANTHINE
 Mechanism of action: These drugs are weak CNS
stimulants that are powerful smooth muscle
relaxants thus they relax the smooth muscle of
bronchi. They also have diuretic effect.
15

DRUG EXAMPLES & DOSES
16

 Indication/Uses
 To treat and prevent bronchospasm.
 To treat asthma, bronchitis, emphysema.
 Contraindications/ Precautions
 Hypersensitivity to any xanthine.
 Infection or irritation of rectum or lower portion.
 Give cautiously in neonates, in elderly patients,
heart disorders, hepatic disorders.
17

ADVERSE EFFECTS
 Headache.
 Anxiety.
 Nausea.
 Seizures.
 Abdominal Cramping.
 Diarrhea.
 Respiratory arrest.
 Irritability.
 Insomnia.
 Vomiting.
 Peptic ulcer.
 Epigastric pain.
 Tachycardia 18

DRUG INTERACTIONS
 (beta) Blocker may antagonize the effects of
methylxanthines.
 Erythromycin may increase the half life of
methylxanthines, and increasing the risk of
methylxanthines toxicity.
 Rifampicin, phenobarbital phenytoin, cigarette
smoking and charcoal – broiled food may shorten
the half-life of drugs and reducing their
effectiveness.
19

NURSING RESPONSIBILITIES
 Nurse should assess for signs and symptoms of
toxicity.
 Nurse also should know that therapeutic sr. level of
theophylline ranges from 10 to 20 mcg/ml.
 Advise patients to decrease consumption of
xanthine – containing food and beverages.
 To detect toxicity, nurse should monitor serum
drugs levels.
20

ANTI INFLAMMATORY AGENTS
Corticosteroids
Mast cell
stabilizers
21

MAST CELL STABILIZERS
 Mast cell stabilizers works to prevent allergy cells
called mast cell from breaking open and releasing
chemicals that help to cause inflammation.
 They are not effective once the allergic reaction has
occurred and mediators are released from mast
cells. So they are useless during asthmatic attack.
They are used in the prophylaxis of asthma.
22

MECHANISM OF ACTION
 They inhibit mast cell activity, thus prevent the
release of allergic mediators like histamine,
serotonin, prostaglandins, cytokines. These
chemical are essential for an inflammation and
allergic reactions.
23

DRUG EXAMPLES AND DOSES
24

 Indication / uses
 Prevent asthma symptoms from occurring or
prophylaxis to asthmatic attack.
 To decrease inflammation or bronchospasm.
 To decrease allergic reactions.
 Rhinitis/conjunctivitis.
 Contraindications/ precautions
 Hypersensitivity.
 Precautiously with renal dysfunction, hepatic
dysfunction.
 Lactation, Cardiac arrhythmias.
25

ADVERSE EFFECTS
 Throat irritations.
 Nasal irritations.
 Wt. Gain.
 Headache.
 Drowsiness.
 Dry mouth.
 Dizziness.
26

 Not reported
 Nurse should monitor drugs adverse reactions.
 Instruct patients that this drug is not effective in an acute
attack.
 Nurse should instruct the patient how to use metered –
dose inhaler or nebulizer.
 If more than one inhalation is ordered, advise patient to
wait 1-2 minutes before taking second puff.
 If the parents is also receiving an inhaled bronchodilator,
advise the patient to use bronchodilators first to open
the airways and then wait approximately 5min before
using cromolyn sodium to maximize its effectiveness.

27

 Anti-Inflammatory Drugs (Cortico-steroids)
 These drugs have antiinflammatory as well as
antiallergic actions thus they are effective in
bronchial asthma.
 Mechanism of action
 They prevent the release of or counteract the
bronchial mediators (Kinins, serotonin, Histamine)
that cause tissue inflammation responsible for
edema and airway narrowing.

28

DRUG EXAMPLE AND DOSE
29

INDICATION/USES
 Chronic bronchitis.
 Allergic Rhinitis.
 Respiratory inflammatory disorders.
 Bronchial asthma.
 Prophylaxis in exercise induced asthma.
 Allergic reaction.
30

 Contraindications/precautions
 Acute bronchospasm.
 Use cautiously in patients who are
immunosuppressed and in those taking prednisone
or other corticosteroids.
 Use very cautiously in patients with viral respiratory
infections.
 Adverse effects
 Hoarseness.
 Candida infections.
 Oropharyngeal irritation.
 Bronchospasm after inhalation of dry powder.
31

 Drug interaction
 Generally Not reported but can be find drug
specific.
 Nurse should instruct the patient to rinse his mouth,
after using inhaled steroids.
 Nurse should teach the patient to:
 Use bronchodilators several minutes before
glucocorticoid inhaler.
 Rinse mouth after using inhaled steroids.
 Use and care for inhaler properly
32

ANTIHISTAMINES
 Antihistamines are the drugs used in the treatment
od allergic disorders and some other conditions.
 These drugs block the effect of histamine and its
receptors. They also provide some sort of sedation.
33

TYPES
1
• Highly
sedatives
2
• Moderate
sedatives.
3
• Mild
sedatives
4
• Non
sedatives
34

INDICATIONS/USES
 Allergic reactions (Hay fever, Vasomotor rhinitis
urticaria, asthma, Anaphylaxis).
 Because of their anticholinergic actions they are
used as antiemetics and useful in motion sickness.
 As hypnotics, Mild sedative/anxiolytics.
 Parkinsonism.
38

CONTRAINDICATIONS/PRECAUTIONS
 Hypersensitivity.
 Lactation.
 Hypokalemia.
 Neonate.
 Coma.
 Special precautions in acute asthma and
pregnancy, elderly, epilepsy.
39

ADVERSE EFFECTS
 Drowsiness in common.
 Delirium.
 Convulsions
 Due to anticholinergic effect
 Urinary retention.
 Constipation.
 Dryness of mouth.
 Blurring of vision. .
 Severe toxicity may causes death to cardiac and
respiratory failure.
40

 Antihistamines are best given in the evening since
all antihistamines cause drowsiness.
 Advise to patient not to drive vehicle or do not
operate machinery.
 Advise to patient to avoid sedative such as alcohol
or sedative hypnotics.
41

LEUKOTRIENE INHIBITORS:
 They act against one of the inflammatory
components of asthma and provide protection
against bronchoconstriction when taken before
exercise or exposure to allergen or to cold air.
 Examples of leukotriene inhibitors include
montelukast and zafirlukast
42

 Side effects
 Abdominal pain
 Thirst
 Headache
 Hyperkinesia (in young children)
 Cautions
 Should not be used for the treatment of acute
asthma attacks
 Caution in pregnancy and breastfeeding
43

ANTI IMMUNOGLOBULIN E (ANTI-IGE)
 Action by blocking immunoglobulin E,which causes of
inflammation in allergic asthma.
 Anti-IgE therapy is only available by prescription. Unlike
other asthma medications, it is not administered by pill
or by inhaler. It needs to be injected once every two or
four weeks by a doctor or other trained healthcare
professional.
 Example is omalizumab (Xolair®).
 Side Effects
 The most common side effects of anti-IgE therapy are:
skin irritation or reaction at the site of the injection, and
respiratory tract infections (e.g., common cold).

44

MUCOACTIVE AGENT
 Mucoactive agents are a class of drugs which aid
in the clearance of mucus from the upper and lower
airways, including the lungs, bronchi, and trachea.
 Mucoactive drugs include expectorants, mucolytics,
mucoregulators, and mucokinetics.
 These medications are used in the treatment
of respiratory diseases that are complicated by the
oversecretion of mucus.
 The drugs can be further categorized by
their mechanism of action
45

TYPES
 Expectorants – increase airway water or the
volume of airway secretions
 Mucolytics – thin (reduce the viscosity of) the
mucus
 Mucokinetics – increase transportability of mucus
by cough
 Mucoregulators – suppress underlying
mechanisms of mucus hypersecretion
46

MUCOLYTICS
 These drugs reduced the viscosity of sputum that
leads to easily expel the sputum.
 Decrease mucous viscosity by breaking or altering
mucoproteins present in sputum.
47

DRUG EXAMPLE & DOSES
48

 To treat abnormal viscid, or thick and hard mucus.
 As an antidote for acetaminophen overdose
(acetylcysteine).
 Contraindications/precautions
 Hypersensitivity to these drugs.
 Cautiously in elderly, pregnant or breast feeding
mothers.
49

 Adverse effects
 Stomatitis.
 Drowsiness.
 Bronchospasm.
 Nausea/vomiting.
 Severe rhinorrhea.
 Activated charcoal decreases acetylcysteine
effectiveness.
 Incompatible with chlortetracycline, erythromycin,
amphotericin B, Hydrogen peroxide.
50

 To assess the airway and maintain it patent.
 Provide suction if needed.
 Assess the pattern breath sounds, cough, and
bronchial secretions.
 Advise patient to maintain a fluid intake of 2-
3litres/day.
 Warn the patient about the rotten egg smell of
acetylcysteine.
51

DECONGESTANTS
 A Decongestant drugs used to relieve nasal
congestion in upper respiratory tracts.
 Decongestants are sympathomimetic drugs that act
by stimulating the α (alpha) – adrenergic receptors.
The decongestant effect due to vasoconstriction of
the blood vessel in the nose sinuses etc. the
vasoconstriction effect reduces swelling or
inflammation and mucous formation in the nasal
passage and make it easier to breath.
52

DRUG EXAMPLES AND DOSES
53

INDICATIONS /USES
 For temporary relief of nasal congestion due to
common cold.
 Hay fever.
 Sinusitis.
 Upper respiratory tract allergens.
 To promote nasal and sinus drainage.
54

CONTRAINDICATIONS/PRECAUTIONS
 Hypersensitivity to these drugs.
 MAO (Monoamine oxidase) inhibiters drugs
therapy.
 Use cautiously in older age patient they are more
likely to experience adverse reaction.
 Nasal contestant should not be used for more than
three days, and oral decongestant should not used
more than 7days because prolonged use will result
in rebound congestion.
55

ADVERSE EFFECTS
 Arrhythmias.
 Tachycardia.
 Insomnia.
 Palpitation.
 Hypertension.
 Drowsiness.
 Hypersensitivity reactions including rash, urticaria.
56

 If given with other sympathomimetic amines may
increase central nervous system stimulation.
 If given with MAO inhibiters may cause severe
hypertension.
 Nurse should assess adverse effect of drugs.
 Monitor pulse rate, BP, and ECG.
 Advise patient not to share the container with other
people and not allow the tip of the container to
touch the nasal passage to avoid contamination.
57

DRUGS FOR COUGH
Antitussive Expectorants. Bronchodilators
58

ANTITUSSIVES (COUGH CENTER
SUPPRESSANT)
 Opioids – Codeine, pholcodine.
 Non opioids – Noscapine, dextromethorphan.
 Antihistamine – Chlorpheniramine diphenhydramine
59

EXPECTORANTS
 Bronchial secretion enhances – Sodium or
Potassium Citrate, Potassium Iodide, Ammonium
Chloride.
 Mucolytes – Bromhexine ambroxol, Acetylcysteine.
60

ANTITUSSIVES
 They are used to suppress dry cough mostly
because their aim to control rather than eliminate
cough. These are also called cough center
suppressants.
 These are the drugs that act in the CNS to increase
threshold of cough center.
61

DRUG EXAMPLE & DOSES
62

 Dry & unproductive cough.
 Allergic cough.
 Spasmodic cough.
 Contraindication/precautions
 Respiratory Depression.
 Asthmatics.
 Convulsion disorder.
 Contraindicate while driving.
 Obstructive airway disease.
63

 Assess the side effects or adverse reaction during
the therapy.
 Special precaution should be keep in mind before
drug administration.
 Advise to patient not to driving after taken opioids
drugs such as codeine pholecodiene.
64

EXPECTORANTS
 These drugs help in removal of secretions of
respiratory tract and mucolytic agents produce
liquification of mucous making expectoration easier.
 They increase bronchial secretions or reduce its
viscosity, sodium and potassium citrate increase
bronchial secretion by salt action also these drugs
stimulate gastric mucosa or directly acting on
mucous membrane of lungs to increase the
secretion of mucous.
65

 Chronic productive cough.
 Thick mucous production.
 Combinations with antitussives drugs for relieving
cough.
 Adverse effect
 Allergic reactions / hypersensitivity.
 Rhinorrhea.
 Lacrimation.
 Gastric irritation.
 Contraindication/precautions
 History of peptic ulceration.
 Asthmatic patients.
 Severe hepatic or renal function.
66

 They may increase the risk of bleeding when use
with anticoagulants.
 Advise to take plenty of fluid during this therapy to
easier removal of thick mucous.
 Assess the adverse effect
67

INHALATIONAL DRUG DELIVERY DEVICES
 The majority of puffers need to be washed regularly
to avoid blockage
 The recommended frequency of washing ranges
from daily to monthly, depending on the device.
 Refer to the specific product information for
directions.
 Patients should shake the device every time before
using it.
 If there appears to be very little liquid inside the
canister when shaken, it is time to replace it
68

TECHNIQUE IN THE USE OF MDIS
 Check patient technique and demonstrate the correct
technique (if necessary) at every opportunity. It has
been shown that there is deterioration in technique
within two months of correct demonstration.
 The device should be held upright with the mouthpiece
at the bottom. This allows an accurate dose to be
dispensed into the actuator valve.
 Deposition of the drug from the inhaler to the airway is
achieved by coordinating the actuation of the puffer and
inhalation of the aerosol mist.
 Starting at the end of a normal expiration, the puffer
should be actuated once at the same time as a slow
deep inspiration through the mouth is undertaken. At the
completion of the slow deep inspiration, the breath
should be held for approximately 10 seconds.
70

TYPES
 There are two techniques which are both
satisfactory if performed well:
 Closed mouth – where the lips are sealed
around the mouthpiece of the MDI.
 Open mouth – where the inhaler is held up to 6
cm away from the mouth.
71

SPACER DEVICES
72

 Inhalation of aerosol from the spacer should
commence as soon after actuation as possible
to minimise deposition in the spacer and loss of
the drug.
 One actuation of MDI per inhalation is
recommended.
73

TECHNIQUE IN THE USE OF SPACER DEVICE
 The proper use of a spacer is as follows:
 Shake the MDI before use.
 Insert MDI, mouthpiece down, into the spacer.
 Actuate the MDI.
 Inhale slowly and deeply from the spacer (starting as
soon after actuation as possible).
 Hold breath for 10 seconds.
 Two modifications of the use of spacer devices may be
applicable for children:
 Take four to six tidal breaths to inhale the aerosol.
 Use a face mask adapter to inhale from the spacer (for
infants and young children).
74

CARE OF SPACER DEVICES
 Spacers should be washed before initial use and at
least monthly thereafter.
 Use kitchen detergent mixed with warm water.
 Leave to drain (without rinsing) and allow to dry
before use.
 A cloth should not be used to dry the spacer as this
can produce an electrostatic charge causing drug
particles to adhere to the walls of the spacer.
 Before using the spacer, it should be ‘primed’ by
actuating three to five doses of the drug. This
minimizes fluctuations in inhaled doses due to
variation in electrostatic charge.
75

REFERENCES
 Dr. P.K. Panwar, Essentials of pharmacology for nurses,
AITBS pub. 2017, India, Pg no. 49 – 62.
 Dr. Suresh k sharma, Textbook of pharmacology,
pathology & genetics for nurses, Jaypee pub. 2016 India
Pg no 161 – 205.
 Tara v. Shanbhag, Smita shenoy, Pharmacology
preparation manual for undergraduate, Elsevier pub.
2014. Pg no. 226 – 257.
 Marilyn Herbert – Ashton, Nancy Clarkson,
Pharmacology, Jones & Barlet pub 2010 India, Pg no
225-258.
 Govind s. Mittal, Pharmacology at a glance, Paras
medical book pub. 2009 India 18 – 19.
 Madhuri Inamdar, Pharmacology in nursing, Vora
medical pub. 2006 India 1 st edition, Pg no 92 – 98 76

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