RESPIRATORY PHARMACOLOGY
By:
Jesus Mario A. Lopez Jr., RN, RTRP
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References:
- Egan’s Fundamentals of Respiratory Care by Kacmarek, Wilkins,
Stoller, 11th edition
- Essentials in Respiratory Care by Kacmarek, 3rd edition
- Rau’s Respiratory Care Pharmacology by Gardenhire, 8th edition
- Oakes Respiratory Care An Oakes Pocket Guide 9th edition
by Dana Oakes
13 Rights of Medication
1. Right patient
2. Right drug
3. Right dose
4. Right time
5. Right route
6. Right drug preparation
7. Right documentation
Administration
8. Right of the patient to refuse
9. Right Education
10. Right of the client to know the reason for the drug
11. Right Assessment
12. Right Evaluation
13. Right Attitude/Approach
Parts of a Prescription Pad
Common Drug Administration
Common Drug Administration
Receptor
–A structure or site on the surface of a cell that is able
to bind a chemical substance which gives rise to a
change either within the cell or the cell in turn releases
a chemical substance
Terminology
–Differing types: bind with specific types of chemical
substances
Agonist
–A chemical substance that binds to a receptor to
produce or amplify a physiological response
Antagonist
–A chemical substance that binds to a receptor
inhibiting other chemical substances from
binding to site, preventing or reducing a
physiological response
Adrenergic agents
- β-Adrenergic: Relaxation of bronchial smooth
muscle and bronchodilation, to reduce Raw and to
improve ventilatory flow rates in
airway obstruction resulting from COPD, asthma, CF,
Terminology
acute bronchitis.
ά-Adrenergic: Topical vasoconstriction and
decongestion used to treat upper airway swelling
Anticholinergic agents
- Relaxation of cholinergically induced
bronchoconstriction to improve ventilatory flow
rates in COPD and asthma
Antimuscarinic bronchodilator
- Same as anticholinergic bronchodilator—agent that
blocks the effect of acetylcholine at the cholinergic site
Mucoactive agents
- Modification of properties of respiratory tract mucus;
current agents reduce viscosity and promote clearance
Terminology
of secretions
Corticosteroids
- Reduction and control of airway inflammatory
response usually associated with asthma
(lower respiratory tract) or with seasonal or chronic
rhinitis (upper respiratory tract)
Antiinfective agents
- Inhibition or eradication of specific infective agents
I. ADRENERGIC; SYMPATHOMIMETICS (FRONT
DOOR BRONCHODILATORS) -Selective
Beta 2- adrenergic receptor agonist
Terminology
A. Catecholamines (e.g. epinephrine – Adrenalin
(IV), Primatene Mist, Medihaler-Epi)
B. Resorcinol (e.g. metaproterenol - Alupent,
Metaprel, terbutaline)
C. Saligenin (e.g.albuterol - Proventil, Ventolin)
D. Other
1. pirbuterol - Maxair Autohaler
2. levalbuterol - Xopenex
3. salmeterol – Serevent
4. formoterol – Foradil, Perforomist
5. aformoterol - Brovana
II. SYMPATHOMIMETIC DECONGESTANTS
A. phenylephrine -Neo-Synephrine, Coricidin
(alpha adrenergic nasal
decongestant)
Terminology
B. racepinephrine – S2,
C. racemic epinephrine -Vaponephrine
III. PARASYMPATHOLYTICS; ANTICHOLINERGICS,
ANTIMUSCARINICS (BACK DOOR
BRONCHODILATORS) - These drugs
act by blocking cholinergic parasympathetic receptors,
thus working against bronchonstriction
A. atropine
B. ipratropium bromide - Atrovent
C. tiotropium bromide - Spiriva
IV. XANTHINES: METHYLXANTHINES (SIDE DOOR
BRONCHODILATORS) - These drugs are
phosphodiesterase inhibitors. This
inhibitor drug indirectly increases
the amount of cAMP within smooth muscle. The
Terminology
increased amount of cAMP then causes
bronchodilation.
A. theobromine
B. theophylline -Aminophylline, Theo-Dur
C. caffeine
V. MUCOLYTIC
A. acetylcysteine – Formerly: Mucomyst or
Mucosil (now generic only)
B. dornase alfa -Pulmozyme
C. sodium bicarbonate?
VI. MAST CELL STALIZERSIMEDIATOR
ANTAGONISTS
Terminology
A. cromolyn sodium –Generic (formerly Intal
and Aarane), Nasalcrom
VII. ANTI-LEUKOTRIENE
A. zileuton (Zyflo)
B. zafirlukast (Accolate)
C. montelukast (Singular)
Common Aerosolized Drugs
Ultra-Short-Acting β2 Brand Name Time Course Preparation
Agonist (Onset, Peak,
“USABA”(emergency, Duration)
urgency),
*Epinephrine Adrenaline 1-3mins Ampoule/vial (0.25-
5-20 mins 0.5 ml + 2cc PNSS)
*&**Racemic 1-3 hrs
epinephrine
*– only used prior to extubation.
** - IS
GIVEN PRIMARILY AS A DECONGESTANT AND NOT FOR
ITS BRONCHODILATING EFFECTS
- not advisable for patients w/cardiac problems.
Common Aerosolized Drugs
Short-Acting β2 Agonist Brand Name Time Course Preparation
“SABA”(rescue, (Onset, Peak,
relievers), Front Door Duration)
Salbutamol/Albuterol Ventolin, Asmalin, UDV, pMDI, DPI
Aerovent
Atrovent
*Ipratropium Br 2-5 mins UDV, pMDI
30- 60 mins
Salbutamol + *Ipratropium Br Combivent, 2-6 hrs
Duavent, Combipul UDV, pMDI,
Pibuterol Maxair Autohaler pMDI,
Bricanyl, Brethaire Ampules, UDV pMDI
**Terbutaline HCL
*- compatible for cardiac patients & patients w/ excessive
secretions; not for patients w/ glaucoma; can cause dry mouth
** - not advisable for pregnant women at any trimester.
Common Aerosolized Drugs
Short-Acting and Long- Brand Name Time Course Preparation
Acting β2 Agonist (Onset, Peak,
combinations Duration)
*Ipratropium Br + Berodual pMDI, UDV
Fenoterol 2-15 mins
30- 60 mins
12-24 hrs
*- compatible for cardiac patients & patients w/ excessive secretions; not for
patients w/ glaucoma; can cause dry mouth
- commonly used by COPD patients
Common Aerosolized Drugs
Long-Acting β2 Agonist Brand Name Time Course Preparation
“LABA” (preventers, (Onset, Peak
controllers), Back Door Duration)
*Salmeterol Serevent pMDI, DPI,
45-90min
*Formoterol Foradil 3-5 hrs pMDI
12-24hrs
*Tiotropium Br Spirivia DPI
*- THESE ARE FOR MAINTENANCE , NOT FOR RESCUE!!!
Common Aerosolized Drugs
Ultra-Long-Acting β2 Brand Name Time Course Preparation
Agonist “ULABA” (Onset, Peak,
(preventers, controllers), Duration)
Back Door
Incanderol maleate + Ultibro 30- 90 mins DPI
Glycopyrronium bromide 3-6 hrs
12-24hrs
*- THESE ARE FOR MAINTENANCE , NOT FOR RESCUE!!!
Common SIDE EFFECTS OF Ultra-short to
Ultra long acting β 2 AGONIST
- Tachycardia (most common)
- Muscle tremors (2nd most common)
- Headache
- Dizziness
- Nausea
- Hypokalemia
- Loss of bronchoprotection?
- Tolerance (tachyphylaxis)
- Cough, dry mouth (for Anticholinergic)
- Glaucoma (for Anticholinergic)
- Dry mouth (for Anticholinergic)
- Flu-like symptoms (for Anticholinergic)
- Fluid Overload (for continuous nebulization)
Common Aerosolized Drugs
Corticosteroids Brand Name Time Course Preparation
(preventers, (Onset ,Duration)
controllers)
*Fluticasone Flixotide pMDI, UDV
propionate 60 mins
12 - 24 hrs
*Budesonide Budecort
Asmavent
Bronex
*- THESE ARE FOR MAINTENANCE, NOT FOR
RESCUE!!!
- Rinse/gargle/ brush mouth thoroughly after
taking the dose then spit water out
Common SIDE EFFECTS of Corticosteroids
SYSTEMIC
- Adrenal insufficiency - Extrapulmonary allergy???
-Acute asthma
- Hypothalamic Pituitary Adrenal (HPA) axis suppression (minimal,
dose-dependent)
- Growth retardation (for chronic users)
- Osteoporosis
LOCAL (TOPICAL)
- Oropharyngeal fungal infections - Dysphonia
- Cough - Oral thrush
- Bronchoconstriction (most common)
OTHER
- Cushingoid state (for chronic users)
- Water retention (for chronic users)
-Weight gain (for chronic users)
Common Aerosolized Drugs
Combination Drugs Brand Name Time Course Preparation
(Long-Acting β2 + (Peak, Onset
Corticosteroids) Duration)
Fluticasone + Salmeterol Advair pMDI
30-60 mins
Budesonide + Formoterol Symbicort 6-12 hrs pMDI, DPI
24 hrs
*- THESE ARE FOR MAINTENANCE, NOT FOR
RESCUE!!!
- Rinse/gargle/ brush mouth thoroughly after
taking the dose then spit water out
Common Aerosolized Drugs
MucoActive Agents Brand Name Time Course Preparation
(Peak, Onset
Duration)
*Ambroxol HCL Mucosolvan 2-3cc + 2cc PNSS
*Acetycysteine Fluimucil 1amp + 2cc PNSS
Variable
* 3% NaCl (2-4cc) 2tabs NaCl +100cc
sterile H20;
*7% NaCl(2-4cc) 5tabs NaCl+ 100cc
sterile H20
** 0.9% NSS (PNSS) None
* - Never mix with other drugs; use bronchodilators first before
administering these.
** - only diluting agent compatible for all aerosolize drugs.
(DON’T USE WITH NSS +D5/DEXTROSE combination!!!)
Common Aerosolized Drugs
Other Brand Name Purpose Preparation
Bland Aerosol For humidification n/a
(Distilled/Sterile )
*Morphine S04 2nd fastest route Ampoule/vial (0.25-
0.5 ml + 2cc PNSS)
*NaHC03 Reduce the viscosity of Manufacturers
airway secretions. specifications
?Heparin Leo Heparin Used to prevent broncho Manufacturers
constriction in exercise
induce asthma specifications
?Alteplase For stroke patients
Manufacturers
?Insulin To lower sugar levels specifications
Manufacturers
?Gluthathione Antioxidant
specifications
Common Aerosolized Drugs
Other Brand Name Purpose Preparation
?Cisplatin, Doxorubicin For Chemo therapy Manufacturers
specifications
* - Never mix with other drugs; use
bronchodilators first before administering
these.
? – still on experimental phase further studies needed.
Other Respiratory Drugs
Non-steroidal anti Brand Name Time Course Preparation
asthma (preventers, (Onset, Duration)
controllers)
Theophylline Theochron, Tablet, syrup, elixir
(Xanthines,) Elixophyllin,
Theodur
Aminophylline Aminophylline Tablet, injectables,
(Xanthines, ) Variable – up to suppositories
24hrs
*Montelukast (ANTI- Singulair
Tablet
LEUKOTRIENE)
Intal pMDI, UDV,
*Cromolyn sodium
ampule
(MAST CELL STALIZERS
IMEDIATOR
ANTAGONISTS)
*- THESE ARE FOR MAINTENANCE , NOT FOR RESCUE!!!
Common SIDE EFFECTS OF Xanthines
Central Nervous System • Hematoemesis
• Headache • Gastroesophageal reflux
• Anxiety Respiratory System
• Restlessness • Tachypnea
• Insomnia Cardiovascular System
• Tremor • Palpitations
• Convulsions •Supraventricular tachycardia
Gastrointestinal System • Ventricular arrhythmias
• Nausea • Hypotension
• Vomiting Renal System
• Anorexia • Diuresis
• Abdominal pain
• Diarrhea
Anti-infectives
Aerosolized antiinfectives Brand Name Time Course Preparation
(Onset, Duration)
Ribavirin (anti viral) Virazole SPAG (vial)
Tobramycin (antibacterial) TOBI Vial
Vial
Aztreonam (antibacterial) Cayston
Ampule
Colistimethate (antibacterial) Colomycin,
Coly-mycin, * See
Colistin manufacturers
specifications
- check for hypersensitivity to these drugs
Common SIDE EFFECTS OF ANTIINFECTIVES
- Deterioration of - Hearing impairment - Neurotoxicity
pulmonary - Hepatotoxicity - Nephrotoxicity
function - Acoustic nerve damage - Bronchospasm
- Dyspnea - Nephrotoxicity
- Chest soreness - Resistance to
- Bacterial pneumonia
- Apnea Pseudomonas infections
- Cardiac arrest
- Hypertension
- Pneumothorax
- Digitalis toxicity
- Rash
- Conjunctivitis
- Reticulocytosis
**Check hospital policy
before administering
SPECIAL CONSIDERATIONS:
-If medications where not given, document medicines
were not given and it’s reason in full detail
-Indicate STAT medicines given, it’s indication, time ,
evaluate it’s effectiveness
-Write the whole drug name instead of ditto’s and short
cut abbreviations
-ALL MEDICATION ORDERS MUST BE IN WRITTEN
REFERRALS VERBAL ORDERS IS A NO-
NO !!!!
SUMMARY:
1. Actual dosages in each clinic/institution may vary.
Consult the Department Policy and Procedure Manual
2. Not all adverse reactions are listed. Consult product
information.
3. DO NOT USE medication if solution is pinkish to
brown in color, cloudy or contains a precipitate.
4. MIXING BRONCHODILATORS
a. Bronchodilators of the same type
(sympathomimetics or “front-door”) should not be
mixed together (e.g. metaproterenol, terbutaline,
albuterol). The exception is a short-acting agent being
used with a long-acting agent.
SUMMARY:
b. Bronchodilators that work by a different
mechanism may be given together such as giving a
sympathomimetic (front-door) with an
anticholinergic (back-door) or an
anticholinergic with a (side-door).
5. DRUG REACTIONS
a. If you suspect a drug reaction, REMEMBER:
-Stop the treatment
-Monitor vital signs
-Stay with the patient until vital signs are stable
- Assure patient safety
-Call the nurse, your supervisor and the physician
- Document thoroughly Include adverse reactions
