chapter 30 lower respiratory

Saline Solutions

Actions: Hydrate mucus, reduce viscosity Administration and uses Nebulizer: expectorants Hypotonic inhalation: distant airway expectoration Hypertonic inhalation: hydration, expectoration Nose drops: nasal decongestion d/t low humidity Nursing implications VERY SAFE! Commonly given to pediatric patients who cannot take antihistamines or cough suppressants. Therapeutic outcome: moisturized mucous membranes for less irritation from dryness.

A patient reports a harsh, nonproductive cough and muscle aches that have lasted for 5 days. There is no sore throat, temperature elevation, or swollen lymph nodes, but the patient is coughing so much that sleeping at night is difficult. Which type of medication will likely be prescribed for this patient? A)Decongestant B)Antitussive C)Antibiotic D)Expectorant

Answer: B Rationale: An antitussive is a cough suppressant used to quiet a cough by acting on the cough center of the brain. It is used when the patient has a dry, hacking, nonproductive cough. Antitussives will not stop the cough completely but should decrease the frequency and suppress the severe spasms that prevent adequate rest at night.

A patient has a history of emphysema and has been coughing for a prolonged period after waking in the morning. The patient is having difficulty clearing the thickened mucus from the lungs. Which type of medication does the nurse anticipate will be ordered for this patient? A)Diuretic B)Antibiotic C)Antitussive D)Mucolytic

Answer: D Rationale: A mucolytic drug will cause the mucus in the patient's lungs to separate and liquefy, thereby reducing viscosity. This allows for easier removal of secretions by coughing, percussion, and postural drainage. An antitussive would only retain secretions and increase the risk of a respiratory infection. There is no clear indication for the use of antibiotics in this patient.

Drugs: ipratropium bromide (Atrovent), tiotropium bromide (Spiriva)

Drug Class: Anticholinergic Bronchodilating Agents Actions: inhibit cholinergic receptors, bronchodilate Uses Prophylaxis, maintenance of bronchospasm d/t COPD (both) Maintenance Tx of asthma with beta agonist (Atrovent) Relief of rhinorrhea d/t allergic rhinitis & common cold (Atrovent) Nursing implications Assessment: VS, pulse ox, hx of closed-angle glaucoma Monitoring: common ADRs: dry mouth, throat irritation Monitoring: serious ADRs: tachycardia, urinary retention Drug interactions: None Used in combination with beta-adrenergic bronchodilators. Best used for prophylaxis and maintenance and not for acute attacks. Tiotropium longer in duration of action than ipratropium. Administration - Atrovent aerosol Clear throat and mouth of sputum Insert metal canister into clear endo f mouthpiece Remove protective cap, invert canister, shake Enclose mouthpiece with lips Exhale deeply through mouth or nose Inhale slowly while pressing on canister base Hold breath for a few sec, remove mouthpiece, exhale Wait 15 seconds, repeat inhalation Replace protective cap, clean mouthpiece after use Administration - Atrovent nasal spray Two sprays into each nostril 2-3 x/d Administration - Spiriva One capsule daily, administered via HandiHaler inhaler Open dust cover and mouthpiece of inhaler Place capsule in center chamber Close mouthpiece until you hear a click Press piercing button and release Clear throat and mouth of sputum Breath out completely Close lips tightly around mouthpiece and inhale slowly and deeply to cause capsule vibration Hold breath as long as comfortable and take inhaler out of mouth Resume normal breathing Open mouthpiece and dispose of used capsule Keep mouthpiece clean

Drugs: Montelukast (Singulair), Zafirlukast (Accolate)

Drug Class: Antileukotriene Agents Actions: Leukotriene receptor antagonists Inhibit bronchoconstriction, edema, mucus formation Uses: asthma maintenance, combined with other meds Nursing implications Assessment: VS, pulse ox, PFTs Administration: PO 1xd (Singulair), PO 2xd (Accolate) Monitoring: common ADRs: nausea, upset stomach, headache Drug interactions: Singulair - none Accolate - aspirin (Accolate toxicity), warfarin (increased risk of bleeds), tehophylline (decreases Accolate effects) Not bronchodilators; given orally. Should not be used to treat acute episodes of asthma. The cysteinyl leukotriene receptor is the one that leukotriene D4 and E4 stimulates to trigger asthma symptoms.

Benzonatate (Tessalon Perles) Codeine, hydrocodone Dextromethorphan (Robitussin, Delsym) Diphenhydramine (Diphen, Tusstat)

Drug Class: Antitussive Agents Actions: Suppress cough center in brain Uses: Suppress disruptive nonproductive cough spasms Nursing implications Assessment: cough characteristics Monitoring: ADRs ALL: drowsiness, constipation Codeine/hydrocodone: allergy, dependence, respiratory depression Dextromethorphan: allergy (rare) Diphenhydramine: sedative, anticholinergic symptoms Drug interactions: CNS depressants Should be used for nonproductive cough only.

Drugs: albuterol (Proventil), terbutaline (Brethine)

Drug Class: Beta-Adrenergic Bronchodilating Agents Actions: Stimulate beta receptors in lungs, bronchodilation Uses Reverse airway constriction d/t asthma, bronchitis, emphysema Treatment of acute airway constriction (short-acting beta blockers) Prevention of airway constriction (long-acting beta blockers) Nursing implications Assessment: VS, pulse ox, palpitations/dysrhythmias, mental status Administration: wait 10 mins between inhalations SABA: use PRN, q3-4hrs; if frequency increases contact dr. LABA: use preventatively with steroids for shortest time possible Monitoring: serious ADRs: tachycardia, tremors, anxiety, N/V, HA Drug interactions: antidepressants, sympathomimetics increase toxicity For specific drugs, see Table 31-5. Therapeutic outcome: easier breathing with reduced wheezing. HR increase: report jump > 20 bpm after administration

Drug: guaifenesin (Robitussin)

Drug Class: Expectorants Action: increase respiratory fluid, decrease mucus viscosity Uses Relieve dry, nonproductive cough Common cold, bronchitis, laryngitis, pharyngitis, sinusitis Nursing implications Assessment: cough type (not for use in chronic, productive cough) Administration: PO tabs, capsules, or syrup; maintain fluid intake Monitoring: common ADRs: GI upset, N/V No significant drug interactions Used in combination with other agents to aid in making a nonproductive cough more productive. Works better if patient is well hydrated

Drug: omalizumab (Xolair)

Drug Class: Immunomodulator Agent Actions: Bind to circulating IgE, inhibit mast cell degranulation Uses: Maintenance of moderate to severe allergic asthma Nursing implications Assess: hx of allergy to drug, positive allergen skin test, VS, PFT, IgE Administration: SubQ q 2-4 wks, special preparation procedure (pg 508) Monitoring: common and serious ADRs Injection site reactions Hypersensitivity Drug interactions: None Administered as a subcutaneous injection given every 2 or 4 weeks. Patients must have a minimum 12-year history of asthma and a positive skin test to airborne allergens and symptoms that are not adequately controlled with inhaled corticosteroids.

Drug: acetylcysteine (Mucomyst)

Drug Class: Mucolytic Agents Actions: Dissolve chemical bonds in mucus Uses: Dissolve abnormally viscous mucus Treat emphysema, bronchitis, asthma, pneumonia Treat acetaminophen poisoning Prevent renal failure d/t contrast media use Nursing implications Assessment: cough, VS, pulse ox, GI symptoms, mental status Administration: solution concentrates as it is used; dilute Wash pt face/hands after use b/c drug is sticky Store: 96 hrs in refrigerator after opening; in plastic/glass container Monitoring: common ADRs N/V d/t smell of rotten eggs Monitoring: serious ADRs bronchoconstriction, bronchospasm Drug interactions: antibiotics will be inactivated Can also be used to treat Tylenol toxicity. Concurrent use of a bronchodilator may be necessary to prevent bronchospasm. Therapeutic outcome: improved airway flow.

Drug: Roflumilast (Daliresp)

Drug Class: Phosphodiesterase-4 Inhibitor Actions: reduces cAMP in lung, blocks inflammation Use: COPD maintenance, combined with other meds Nursing implications Assessment: VS, pulse ox, PFTs, hx of GI dz, HA, fatigue, dizziness, insomnia, anxiety, baseline and weekly weight Monitoring: common ADRs: N/V, diarrhea, HA, weight loss Monitoring: serious ADRs: insomnia, anxiety, depression Drug interactions: Antifungals, antibiotics increase toxicity risk AntiTB, antiepileptics reduce therapeutic effects

Drug: SSKI

Drug Class: Potassium Iodide Actions: increases secretions, promotes expectoration Uses: chronic lung disease asthma, COPD Nursing implications Assessment: cough, pregnancy test (may cause goiter in fetus) Administration: PO, diluted in water/juice; take with food Maintain fluid intake and humidification Monitoring: common ADRs: N/V, diarrhea Drug interactions: K supplements, salt substitutes, K-sparing diuretics: Hyperkalemia Lithium, antithyroid meds: concurrent use = hypothyroidism Patients should notify the prescriber if taking any other medications containing potassium. Concurrent use of humidification in patients taking expectorants helps to decrease the viscosity of secretions. Long-term use may result in goiter; thyroid function tests are important.

Drugs: theophylline (Theo-24), aminophylline

Drug Class: Xanthine Derivative Bronchodilators Action: act on bronchial smooth muscle to cause dilation Uses: asthma, bronchitis, emphysema maintenance Nursing implications Assess: VS, pulse ox, mental status, hx of angina, PUD, DM, glaucoma, hyperthyroidism Administration: around the clock; Theo-24 therapeutic level 10-20mg/L Monitoring: common ADRs: N/V, epigastric pain, abdominal cramps Monitoring: serious ADRs CV: Tachycardia, palpitations Neurologic: tremors, nervousness, restlessness, anxiety, headache Drug interactions Antibiotics, CCB, flu vaccine, leukotriene modifiers: enhance toxicity Beta blockers, smoking: antagonistic activity

Drug: cromolyn sodium (Intal)

Miscellaneous Antiinflammatory Agents Action: Mast cell stabilizer; inhibits release of histamines Uses Treat severe bronchial asthma or allergic rhinitis Prophylaxis of exercise-induced bronchospasm Nursing implications Assessment: ensure pt is not in midst of allergy/asthma attack Administration: Inhalation, effect may take 2-4 wks to appear For prevention: 1-2 metered dose sprays into each nostril, 10-60 mins prior to exposure Monitoring: common ADRs: GI irritation, dry mouth Monitoring: serious ADRs: bronchospasm, coughing Drug interactions: none Used for prophylactic management of bronchospasms and asthma. Also used just before exposure to conditions or substances that cause bronchospasm (wheezing or difficulty in breathing). Will not help an asthma or bronchospasm attack that has already started.

Identify important aspects of patient education for patients receiving drug therapy for lower respiratory disease.

Peak flowmeter use: green, yellow, red zone Avoiding irritants: dust mites, smoke, mold, pets Activity/exercise: plan for rest periods, use B2 agonist Nutrition: avoid mucus producing foods, trigger foods Preventing infections: good hygiene, vaccines! Increased fluid intake: 8-10 glasses H2O/day Environmental control: temperature, humidity, filtration Breathing techniques: pulmonary rehab Sleep patterns: sleep in recliner may be necessary Discuss expectations of Tx, identify support system Medication: purpose, administration, use Peak flow meter: Peak expiratory flow: green = 80-100% of personal best, breathing well Yellow = 50-80% of personal best, take PRN bronchodilator Red = <50% of personal best, contact provider Mucus producing foods: milk, chocolate

Mucolytics

Reduce stickiness of pulmonary secretions, dissolve mucus For: acute/chronic lung obstruction, bronchoscopy prep, tracheostomy care, post chest surgery

Bronchodilators

Relax smooth muscle of respiratory tract For: obstructive lung disease

Antitussives

Suppress cough center in the brain For: dry, hacking, nonproductive cough

Drugs: beclomethasone (QVAR), fluticasone (Flovent)

corticosteroid Actions: Inhibit inflammation, relax smooth muscle Uses COPD unresponsive to bronchodilators Maintenance of asthma Nursing implications Assessment: Inspect oral cavity for infection Administration: full therapeutic benefit may take up to 4 wks Use bronchodilator before steroid to enhance absorption Monitoring: common ADRs: hoarseness, dry mouth Monitoring: serious ADRs: fungal infection (thrush) Drug interactions: none for inhale steroids For specific drugs, see Table 31-6. Aerosols enhance effects of beta agonists, too Daily aerosol, alternate day PO, or short-course daily PO are programs of choice from most to least preferred Patients at risk for thrush antibiotic use, DM, large steroid dose, poor dental hygiene Oral hygiene following inhalation rinse and gargle after each treatmetn

physiological responses of emphysema, bronchitis, and asthma

destruction of alveolar tissue, loss of elasticity of lungs, air trapping irritation of bronchi with excess edema and mucus production chronic inflammation with intermittent reversible air flow obstruction

expectorants

liquify thick mucus For: nonproductive cough, bronchitis, pneumonia

function of lower respiratory

look it up

Anti-inflammatory agents

reduce inflammation; for asthma