Chapter 7 & 8 Pharmacology

After administering an immediate release form of theophylline, serum blood levels should be obtained _________ to _________ hours later.

1 to 2

List 3 indications for the use of Xanthines.

1. Asthma 2. COPD 3. Apnea of prematurity

LIST 5 respiratory care assessments you should preform after delivery of and for long term use of anticholinergic bronchodilator

1. Monitor pulmonary function studies of lung volumes, capacities, and flows. 2. Instruct and then verify correct use of aerosol delivery device (SVN, MDI, reservoir, DPI). 3. Assess ongoing lung function, including predose FEV1, over time. 4. Assess amount of concomitant β-agonist use and nocturnal symptoms. 5. Assess number of exacerbations, unscheduled clinic visits, and hospitalizations.

Match the adverse reactions seen with theophylline with the organ system ____ Diuresis ____ Tachypnea ____ Nausea ____ Anxiety ____ Palpitations ____ Vomiting ____ Headache

1. Renal 2. Respiratory 3. Gastrointestinal 4. CNS 5. Cardiovascular 6. Gastrointestinal 7. CNS

1. T/F The neb dose of ipratropium is more than 10 times greater than the MDI dose which causes greater systemic effects. 2. T/F Patients should use a holding chamber with MDI administration

1. true 2. true

The total does of atrovent HFA in one puff is

17ug

3. T/F With neb delivery the patient must be instructed to keep the mouthpiece in the mouth and a reservoir tube should bevattached to the expiratory side of the T mouthpiece facing away from patient. 4. T/F Face mask delivery is recommended to deliver the maximal dose of the drug

3. true 4. false

A range of _________ to _________ micrograms/ml is now recommended for the treatment of asthma and a range of _____ to _____ micrograms /ml is recommended for the treatment of COPD.

5 to 15 ; 5 to 10

After administering a sustained release form of theophylline, serum blood levels should be measured _________ to _________ hours after the morning dose.

5 to 9

What is the indication for the use of stiollto Respimat? Combination of which two drugs?

A ) long-term treatment of airflow obstruction in pt with COPD b) tiotropiom bromide and olodacteral

List 4 respiratory care assessments you should perform before the delivery of anticholinergic bronchodilator therapy

A. Assess effectiveness of drug therapy based on the indication for the aerosol agent B. Monitor flow rates using bedside peak flow meters, portable spirometry, or laboratory reports of pulmonary function. C. Perform respiratory assessment: Breathing rate and pattern and breath sounds by auscultation, before and after treatment. D. Assess pulse before, during, and after treatment

List 2 respiratory care assessments you should preform during the delivery of anticholinergic bronchodilator

A. Assess patient's subjective reaction to treatment, for any change (positive or negative) in breathing effort or pattern. B. Assess arterial blood gases, or pulse oximeter saturation, as needed, for acute states with COPD or asthma, to monitor changes in ventilation and gas exchange (oxygenation)

2 most common side effects seen with the anticholinergic aerosol ipratropium

A. Dry mouth B. cough

Listed 4 anticholinergic bronchodilators that are indicated as a bronchodilator for maintenance and treatment in COPD, including bronchitis and emphysema.

A. Ipratropium (atrovent) B. Tiotropium ( spriva) C. aclidinium (duoneb, tudorza pressair) D. umeclidinium (incruse ellipta)

A. Tiotropium bromide B. Ipratropium bromide C. Ipratropium bromide and albuterol (MDI) D. Ipratropium bromide and albuterol (SVN) E. Aclidinium bromide F. Umeclidinium

A. Spiriva B. Atrovent C. Combivent D. Duoneb E. Tudorza Pressair F. Incruse Ellipta

The anticholinergic agents ipratropium and tiotrpium are indication for the treatment of _________ in COPD

Airflow obstruction

The combination of umeclidinium and vilanterol is called

Anoro Ellipta

Anti-cholinergic versus B agonist

Anti-cholinergic Onset: slightly lower Peak effect: slower Duration: longer Fall in PaO2: none Site of action: larger, central airways B agonist Onset: faster Peak effect: faster Duration: shorter Fall in PaO2: yes Site of action: central and peripheral airways

An agent that blocks parasympathetic nervous fibers which allows relaxation of smooth muscle in the airway is called

Anticholinergic bronchodilator

A combination of an ____ with a ________ is indicated for use in patients needing regular treatment for COPD and who require additional bronchodilation for relief of airflow obstruction

Anticholinergic, β2 agonists

The word______ has the same meaning as anticholinergic: blocking the effect of ACH at the cholinergic site

Antimuscarinic

Ipratropium bromide is a derivative of

Atropine

What are the pharmacologic effect pf atropine

Atropine sulfate, a prototype tertiary compound, inhibits and reduces mucociliary clearance. Atropine seems to block hypersecretion stimulated by cholinergic agonists in both the lower airway and the nose (upper airway) more than basal secretion. Atropine relaxes airway smooth muscle, the basis for its use in asthma. 1. Tertiary compounds cross the blood-brain barrier and produce dose-related effects. Small doses of 0.5 to 1.0 mg can cause effects that include restlessness, irritability, drowsiness, fatigue, or, alternatively, mild excitement. Increased doses can cause disorientation, hallucinations, or coma. Inhaled atropine has been reported to cause an acute psychotic reaction. They block contraction of the iris to cause pupil dilation and paralyze the ciliary muscle of the lens to prevent thickening of the lens for near accommodation, causing blurred vision. Atropine in small doses causes minor slowing of the heart rate; larger doses increase heart rate through vagal blockade

Which of the following are the only approved anti cholinergic agents for inhalation as an aerosol at this time?

Atrovent Incruse Ellipta Spiriva

MDI can administer what drug

Atrovent and Combivent

SVN can administer what drug

Atrovent and DuoNeb

MDI

Atrovent and Duoneb

SVN

Atrovent and dueneb

What precautions should you take when administering theophylline to patients with bronchiectasis or cystic fibrosis?

Because of the diuretic effect of theophylline, ensure that patients with excess airway secretions (e.g., those with bronchitis or cystic fibrosis) receive adequate fluid replacement to prevent dehydration and thickening of secretions.

what pharmacologic effect does ipratropium and tiotropium have on the respiratory and cardiac system

Bronchodilation with little to no cardiac effect

The U.S, food and drug administration has given approval for ipratropium specifically for use in the treatment of ________and the drug can also be prescribed for the treatment of _______

COPD, asthma

Anticholinergic act primarily on the ____ airways ; B agonist act primarily on the __________airways

Central, peripheral

An agent that produces the effect of ACH is called

Cholinergic

Soft mist inhaler can administer what drug

Combivent Respimat

Ipratropium Bromide (Atrovent)

Does: MDI 17ug/puff, two puffs QID SVN 0.02% solution (0.2 mg/mL), 500 TID, QID Nasal spray 21; 42; two sprays per nostril 2 to 4 times daily Onset: 15 -30 minutes Peak: 1-2 hours Duration: 6 hours

Aclidinium bromide (Tudorza Pressair)

Dosage: DPI 400ug/inhalation, one inhalation BID Onset: 10 minutes Peak: 2 hours Duration: 12 hours

Ipratropium Bromide with Albuterol Sulfate (combivent respimat)

Dosage: SMI ipratropium 20ug/puff and albuterol 100ug/puff, one inhalation QID Onset: 15 minutes peak: 1 to 2 hours Duration: 6 hours

Ipratropium Bromide with Albuterol Sulfate (DuoNeb)

Dosage: SVN ipratropium 0.5 mg and albuterol 2.5 mg Onset: 15 minutes Peak: 1-2 hours Duration: 6 hours

Tiotropium Bromide (Spiriva)

Dosage: dpi 18ug/inhalation, one inhalation daily Onset: 30 minutes Peak: 1-3 hours Duration: 24 hours

Umeclidinium Bromide (Incruse Ellipta)

Dosage: dpi 62.5ug/inhalation, one inhalation daily Onset: 5-15 minutes Peak: 1-3 hours Duration: 24 hours

Umeclidinium bromide and vilanterol (Anoro Ellipta)

Dosage: dpi umeclidinium 62.5 ug/inhalation and vilanterol 24ug/inhalation, 1 inhalation daily Onset: 5-15 minutes Peak: 1-3 hours Duration: 24 hours

The most common side effect seen with aerosolized ipratropium are

Dry mouth and cough

When prescribing theophylline, what must be considered in relation to the metabolism rates of individual patients?

Each person is different so the rates & dosage may differ, the therapeutic range must also be considered

T/F An anticholinergic bronchodilator , because of its action on central large airways, should be given before a B agonist

False

In a large, controlled study, patients with COPD who are given a combination of albuterol and ipratropium show a greater increase in_________ compared with patients given either agents alone

Forced expiratory volume at 1 second (FEV1)

Using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, explain when theophylline could be used as a treatment of COPD. Are there any potential problems with its administration?

GOLD states that inhaled bronchodilators are preferred. However, it can be used as an alternative to inhaled bronchodilators such as β2 agonists or anticholinergics agents. There is a potential for toxicity.

Utibron neohaler is a combination of which two medications

Glycopgyrronium and bromide

Why methacholine is used in bronchial provocation testing

In the normal airway, a basal level of bronchomotor tone is caused by parasympathetic activity. This basal level of tone can be abolished by anticholinergic agents such as atropine, indicating it is mediated by acetylcholine. Administration of parasympathomimetic (cholinergic) agents such as methacholine (e.g., in bronchial provocation testing) can intensify the level of bronchial tone to the point of constriction in healthy subjects and more so in asthmatic patients

The medication commonly used in serve asthma especially bronchoconstriction that does not respond well to B agonist therapy is

Ipratropium bromide

What 2 medications make up combivent

Ipratropium bromide Albuterol

Explain the use of caffeine citrate in premature infants.

Its stimulates breathing

Which of the following could be assessed to determine the effectiveness of tiotropium bromide

Keep a count of the number of exacerbations keep a count of number of unscheduled clinical visits keep account of number of hospitalizations

Parasympathomimetic agent that intensified the level of bronchial tone to the point of bronchial constriction and is used in bronchial provocation testing is

Methacholine

What benefit does caffeine citrate have over theophylline when treating premature infant for apnea of prematurity?

Much safer and wider therapeutic level with fewer side effects

____________ is the same as cholinergic producing the effect of ACH or an agent that mimics ACH

Muscarinic

Besides improving lung function in COPD and controlling symptoms, tiotropium may also be useful for controlling ________symptoms and deterioration of flow rates at nighttime

Nocturnal asthma

Why does administration of an anticholinergic can cause significant bronchodilation

Normally, a basal level of bronchomotor tone is caused by some parasympathetic activity. Administration of an anticholinergic abolishes this tone (allows bronchodilation), and administration of a parasympathomimetic intensifies the tone (causes bronchoconstriction). The degree of bronchodilation that will occur with anticholinergics depends on the degree of tone present, which is the result of parasympathetic stimulation. If parasympathetic stimulation is causing significant bronchoconstriction, then administration of an anticholinergic should result in significant bronchodilation

An agent that blocks parasympathetic nervous fibers are called

Parasympatholytic

A __________ agent produces effects similar to those of the parasympathetic nervous system

Parasympathomimetic

Soft Mist Inhaler

Respimat combievent

It is important to monitor therapeutic levels of theophylline, because levels higher than 45 micrograms/ml can cause __________

Seziure, coma, death

Which of the following is a long-acting bronchodilator that can last as long as 32 hours but usually is limited to 16 to 24 hours because of circadian rhythm?

Spiriva

dry powder inhaler

Spiriva

Dry powdered inhaler can administer what drug

Spiriva, incruse ellipta, tudorza pressair

Patient calls the pulmonary rehabilitation department and tells the therapist that she has been taking incruse ellipta twice per day for the past two days. The RT should tell the patient to

Take the medication once pre day

Atropine is a ______ and not fully ionized; it therefore is readily absorbed into bloodstream is distributed throughout the body crosses the blood brain barrier and causes changes in the CNS

Tertiary ammonium compound

Where in the airway do anticholinergic seem to have their greatest effect

The central airways

Which of the following is true concerning the sequence of administration of an MDI B2 agonist and an anti-cholinergic?

The order of administration is not important

How does the clinical effect for ipratropium differs from that for albuterol

The profile of clinical effect for ipratropium differs from that of inhaled β-adrenergic agonists. The onset of bronchodilation begins within minutes but proceeds more slowly to a peak effect 1 to 2 hours after inhalation. β agonists can peak between 20 minutes and 30 minutes depending on the agent. In asthma, the duration of bronchodilator effect is about the same for ipratropium as for β agonists. In COPD, the duration is longer by 1 to 2 hours

Which of the following describes quaternary ammonium compounds

They do not cause CNS changes

Which three agents are used as triple therapy to help reduce the progression of COPD and improve lung function?

Tiotropium Salmeterol Inhaled corticosteroids

Explain the receptor selectivity of tiotropium bromide. How does this explain once a day dosing?

Tiotropium bromide (Spiriva), a muscarinic receptor antagonist, is a long-acting bronchodilator. -It is poorly absorbed after inhalation. Inhalation of a single dose gives a peak plasma level within 5 minutes, with a rapid decline to very low levels within 1 hour. -In patients with COPD, tiotropium gives a bronchodilating effect for up to 24 hours with adequate dose. -Tiotropium exhibits receptor subtype selectivity for M1 and M3 receptors. The drug binds to all three muscarinic receptors (M1, M2, and M3) but dissociates much more slowly than ipratropium from the M1 and M3 receptors. This results in a selectivity of action on M1 and M3 receptors.

Why is methacholine used in bronchial provasocation testing?

To detect and quantify airway hyper reasponsivness

T/F Because albuterol peaks sooner and terminates sooner and ipratropium peaks slowly and lasts longer they complement each other

True

A physician it's written in order to give a patient combivent: the order provides no other information. How many puffs and how often should the patient receive this treatment

Two puffs QID

A drug with cholinergic effect would result in which of the following

Urination Salivation Secretion of mucus

Parasympathetic neurons from what cranial nerve enter the lung at the hila and travel along the airways

Vagus, cranial nerve X

When sensory C fiber nerves are stimulated , what clinical manifestation may the patient present with

When stimulated, these nerves send an afferent nerve impulse to the CNS. This results in a reflex cholinergic efferent nerve impulse that causes bronchoconstriction, increased secretions, and cough.

How does umeclidinium bromide work

`-Umeclidinium bromide is a long-acting anticholinergic with activity across multiple muscarinic receptors. It works by exerting its bronchodilatory activity by competitively inhibiting the binding of acetylcholine with muscarinic cholinergic receptors on airway smooth muscle (M3). It demonstrates slow reversibility at the M3 receptor providing long duration of bronchodilation in the lungs

List 6 central nervous system (CNS) adverse reactions seen with theophylline treatment

a. Headache b. Anxiety c. Restlessness d. Insomnia e. Tremors f. Convulsions

What are the 2 proposed mechanisms of action by which theophylline and xanthines reverse airway obstruction?

a. Inhibition of phosphoiesterase b. Blockade of adenosine receptors

Given the following levels of serum theophylline, indicate the effect each level could have on the body. a. < 5 b. 10-20 c. >20 d. >30 e. 40-50

a. None b. Therapeutic c. Nausea d. Arrhythmia e. Seizures and above that death

List 4 types of Xanthine derivative used as bronchodilators in obstructive airway diseases. Include both the generic and brand names.

a. Theophylline (Theochron) b. Oxtriphylline (Choledyl SA) c. Aminophylline (Aminophylline) d. Dyphylline (Lufyllin)

List 3 nonbronchodilating effects of theophylline.

a. increases respiratory muscle strength b. increases muscle endurance c. increases ventilatory drive

The anticholinergic agents ipratropium and tiotropium are indicated for the treatment of which of the following in COPD?

airflow obstruction

Combivent is a combination of which two medications

albuterol/ipratropium

True or False: Theophylline decreases cardiac output and increases pulmonary vascular resistance, thus potentially imposing a greater workload on the heart.

false

True or False: When treating apnea of prematurity, it is better to use theophylline than caffeine, because theophylline is a more potent stimulator of the respiratory system.

false

Theophylline is metabolized by the (liver/kidney) and excreted by the (liver/kidney).

liver, kidney

If ipratropium is delivered as an aerosol nebulizer treatment with a mask, what precautions should be taken?

protect the patient's eyes

True or False Long acting beta agonists, such as salmeterol, give more consistent improvement in lung function on a 12-hour basis in patients with COPD.

true

True or False: A nonbronchodilating effect of theophylline is its ability to strengthen the diaphragm directly.

true

True or False: For use in apnea of prematurity, the recommended loading dose is ___20 kg ___, which is equivalent to 10 mg/ml of caffeine.

true

True or False: Most recent guidelines for the pharmacologic management of asthma and COPD suggest Theophylline is not indicated as first line therapy

true

True or False: Theophylline can be used as maintenance therapy in COPD if anticholinergics (ipratropium bromide) and beta agonists cannot control the disease

true

Anoro Ellipta Is it combination of which two medications?

vilanterol and umeclidinium

Anticholinergic may be useful in patients with acute severe episodes of asthma not responding to

β2 agonists