Respiratory Drugs

- Divided into two major parts

A. Upper respiratory tract
- Nares, nasal cavity, pharynx, and larynx
B. Lower respiratory tract
- Trachea, bronchi, bronchioles, alveoli, and alveolar capillary membrane

Upper Respiratory Disorders

● Common cold, acute rhinitis, and allergic rhinitis
○ Common cold- caused by rhinovirus; primarily affects nasopharyngeal tract
○ Acute rhinitis- acute inflammation of the mucous membranes of the nose; usually accompanies common
cold
○ Allergic rhinitis- hay fever; caused by pollen or a foreign substance
*nasal secretion increase in both acute and allergic rhinitis– TAKE NOTE
● Sinusitis
● Acute pharyngitis

MEDICATION USED IN COMMON COLD, ACUTE RHINITIS, AND ALLERGIC RHINITIS

1. Antihistamines
● MOA: Compte with histamine for receptor sites and prevent histamine response
● Two types of histamine receptors: H1 & H2
● H1 receptor stimulation- extravascular smooth muscles constrict
● H2 receptor stimulation- increase in gastric secretion
● First generation antihistamine: easily crossed the blood-brain barrier into the CNS and antagonizes the
H1 receptors leading to a different therapeutic and adverse effect profile
○ Most cause drowsiness and dry mouth
● Second generation antihistamines:
○ Fewer anticholinergic effects and lower incidence of drowsiness
FIRST-GENERATION ANTIHISTAMINES SECOND-GENERATION ANTIHISTAMINES

- Alimemazine - Dimetindene - Bilastine - Ketotifen

- Chlorphenamine - Diphenhydramine - Cetirizine - Levocetirizine
- Clemastine - Hydroxyzine - Desloratadine - Loratadine
- Cyproheptadine - Promethazine - Ebastine - Oxatomide
- Fexofenadine - Rupatadine

SIDE EFFECTS

- Drowsiness - Insomnia
- Dizziness - Fatigue
- Dry mouth - Urinary retention
- Headache - Ataxia
- Weakness - Blurred vision
- Agitation - Rash

ADVERSE REACTIONS

- Palpitation
- Psychosis
- Hypotension
 2. Nasal and Systemic Decongestants
● MOA: Activates post junctional alpha-adrenergic receptors found on pre capillary and post
capillary blood vessels of the nasal mucosa
● Administered intranasal or orally
NASAL DECONGESTANTS SYSTEMIC DECONGESTANTS

- Xylometazoline - Phenylephrine
- Oxymetazoline - Pseudoephedrine
- Saline

SIDE EFFECTS

● Nausea - Headache
● Vomiting - Tremors
● Restlessness - Gastric irritation

ADVERSE REACTIONS

- Cardiac arrhythmias
- Myocardial infarction

3. Intranasal Glucocorticoids
● The most effective treatment for allergic rhinitis
● Provide relief for the four major symptoms of AR: Sneezing, itching, rhinorrhea, and nasal congestion
● MOA: regulate protein synthesis by binding to glucocorticoid receptors thus decreasing synthesis of
pro-inflammatory enzymes
SIDE EFFECTS ADVERSE EFFECTS

● Beclomethasone ● Burning/stinging ● Septal perforation

● Budesonide ● Dryness
● Flunisolide ● Epistaxis
● Fluticasone
● Mometasone furoate
● Triamcinolone

4. Antitussives
● May be taken if cough is unproductive and irritating
● Reduces frequency or intensity of coughing
● MOA: act on the cough-control center in the medulla to suppress the cough reflex
PERIPHERAL CENTRAL PERIPHERAL AND CENTRAL

- Demulcents (lozenges - Narcotic antitussives: Benzonatate

- Steam inhalation (menthol) Codeine Carbetapentane
Pholcodine
- Non-narcotic antitussives:
Dextromethorphan
Noscapine
Levopropoxyphene
Side effects: dizziness, headache, drowsiness, dry mouth, nausea, and vomiting
 5. Expectorants
● Loosen bronchial secretions so they can be eliminated by coughing
● Hydration: best natural expectoraNT
● MOA: reduce the viscosity of tenacious secretions by irritating the gastric vagal receptors that
stimulate respiratory tract fluid, thus increasing the volume but decreasing the viscosity of
respiratory tract secretions

BRONCHIAL SECRETION ENHANCERS MUCOLYTICS

- Guaifenesin - Acetyl cysteine

- Potassium iodide - Bromhexine
- Ammonium chloride - Ambroxol
- Carbocisteine
Side effects: dizziness, headache, constipation, nausea and vomiting

Nursing Interventions

1. Give oral preparation with food

2. Administer IM form in a large muscle (antihistamines)
- Avoid SC injection
3. Avoid driving motor vehicles

Lower Respiratory Disorders

● Chronic Obstructive Pulmonary Disease
○ Chronic Inflammatory lung disease that causes obstructed airflow from the lungs
○ Two most common types
■ Chronic Bronchitis- long term inflammation of the bronchi → increased mucus production
○ Pulmonary Emphysema- persistent airway symptoms and airflow limitation due to airway and/or alveolar
abnormalities

bluish colored skin (cyanosis) –

○ Blue bloater sign that a person has low
■ Generalized term for a person oxygen level
who is blue and overweight ■ When blood oxygen is low, the
■ Present SOB and chronic cough body naturally shunts the blood
■ Blue pertains to the skin around from non vital organs such as
their lips and nails (acrocyanosis), fingertips and lips to vital organs
 which are the lungs and the heart, they are breathing so fast,
and brain. this makes their skin look
○ Pink puffer (pink- color of the skin) pink.
■ Generalized term for a person ■ They usually have large chests.
who is thin, breathes fast, and This used to be called a barrel
pink chest.
■ Usually present SOB and pursed ● It looks like the person’s
lip breathing. chest is always in the
■ It's an old term for what we would inhale position. It gives the
now recognize as severe appearance of a barrel,
emphysema hence the name. It
■ Like blue bloaters, they have happens when air gets
trouble oxygenating. But, their trapped inside your lungs.
bodies compensate for this by Air gets in but some of this
increasing respiratory rate. air cannot get back out.
● This assures that tissues So, this is a common
are adequately feature of severe
oxygenated. But, because emphysema.

● Bronchial Asthma
○ Long term disease of the lungs
○ Airway narrowing, swelling and excessive mucus production
○ On the left, it is a normal airway as compared to the airway of an asthmatic.
○ The walls of the airway are thicker and appear inflamed in asthmatic as compared to the normal airway.
○ An asthmatic airway during exacerbation is even more thicker and inflamed as compared to the two other
airways but now with tightened airways/ tightened smooth muscles.
○ This is where you will appreciate wheezing because the air is now passing through an even tighter
airway– You will hear whistling sounds commonly for exacerbations.
 COMMON TRIGGERS OF ASTHMA
● The best way to avoid exacerbation is to avoid triggers.

MEDICATIONS USED IN LOWER RESPIRATORY DISORDERS

1. SYMPATHOMIMETICS
● Mimic or modify the actions of endogenous
catecholamines of the sympathetic nervous system (fight-or-flight reaction).
● It can also be used for the treatment of cardiovascular pathology, hypersensitivity, COPD, and glaucoma
● MOA: increase cAMP→ bronchodilation (which helps with lungs diseases since the airways are narrowed in
lung diseases to help the patients breathe well, we give them bronchodilators to widen the airways)
● Adrenergic bronchodilators stimulate:
○ Alpha receptor→ vasoconstriction and vasopressor effect
○ Beta 1 receptor→ increased HR and myocardial contractility
○ Beta 2 receptor→ relaxes bronchial smooth muscle, and stimulates mucociliary activity
 I. Alpha and beta adrenergic medications Stimulates

Ephedrine sulfate Alpha 1, Beta 1, Beta 2

Epinephrine Alpha 1, Beta 1, Beta 2

II. Beta adrenergic medications Stimulates

Albuterol Beta 2

Formoterol Beta 2

Levalbuterol Beta 2

Metaproterenol sulfate Beta 1 (some) and Beta 2

Salmeterol Beta 2

Terbutaline sulfate Beta 2

Arformoterol tartrate Beta

Indacaterol Beta

Olodaterol Beta 2
● Adrenergic Bronchodilators
○ Side effects: Hypokalemia, tachycardia, elevated BP, palpitated
○ Adverse reactions: Bronchospasm, cardiac arrhythmia, anaphylaxis

2. ANTICHOLINERGICS
● Used in the treatment of various conditions including COPD, bladder conditions, gastrointestinal disorders, and
symptoms of Parkinson’s Disease
● MOA: Block and inhibit the activity of the neurotransmitter acetylcholine (ACh) at both central and peripheral
nervous system synapses
These are following inhalants:
1. Ipratropium bromide
Anticholinergics 2. Aclidinium
3. Tiotropium
4. Umeclidinium

1. Omalizumab
Monoclonal Antibody 2. Reslizumab
3. Dupilumab

1. Ipratropium and albuterol

2. Indacaterol and glycopyrrolate
Combination beta adrenergic and anticholinergics 3. Olodaterol and tiotropium
4. Umeclidinium and vilanterol
5. Glycopyrrolate and formoterol
6. Aclidinium bromide and formoterol fumarate

● Side effects: Headache, sinusitis, laryngitis, ● Adverse reactions: Cardiac arrhythmias,

dryness and irritation of throat, urinary tract increased intraocular pressure, anaphylaxis
retention
 Adrenergics Medications

1. Beta 2 and some beta 1 Metaproterenol sulfate

2. Beta 2 Albuterol
Salmeterol

Terbutaline sulfate
Formoterol

Indacaterol
Olodaterol
Arformoterol tartrate

Inhalants for Asthma Control

Ipratropium bromide
Anticholinergics Aclidinium
Tiotropium
Umeclidinium

Anti inflammatory drugs

Cromolyn Cromolyn

Beclomethasone
Glucocorticoids (corticosteroids) Budesonide
Flunisolide
Fluticasone

3. METHYLXANTHINE DERIVATIVES
● Stimulates the CNS and respiration, ilate ● Examples
coronary and pulmonary vessels and cause ○ Theophylline- most commonly used
diuresis ○ Theobromine
● MOA: Through non-competitive inhibition of the ○ Caffeine
phosphodiesterase enzyme (PDE), ● Side effects: Headache, diarrhea vomiting
methylxanthines cause an intracellular increase ● Adverse reactions: Cardiac arrhythmia,
in levels of cyclic adenosine monophosphate seizures, anaphylaxis
(cAMP) and cyclic guanosine monophosphate
(cGMP) → bronchodilation

4. LEUKOTRIENE RECEPTOR ANTAGONISTS

● Chemical mediator that causes inflammatory changes in the lungs
● Effective in reducing the inflammatory symptoms of asthma triggered by allergic and environmental stimuli
● MOA: selectively binds to the cysteinyl leukotriene receptor type-1 → substantial blockage of LTD4
leukotriene-mediated bronchoconstriction→ bronchodilation
● Examples: ■ Zileuton
○ Leukotriene Modifiers ● Side effects: Headache, eczema, nausea,
■ Montelukast vomiting, GI upset, epistaxis
■ Zafirlukast ● Adverse reactions: anaphylaxis,
○ Leukotriene Synthesis Inhibitor thrombocytopenia, hallucinations
5. GLUCOCORTICOIDS
● Indicated if asthma is unresponsive to ○Nongenomic actions: rapid cellular
bronchodilator therapy. (If the Pt is still having mechanisms → induce transient
asthmatic attack despite having maximum doses vasoconstriction → reversing
of theophylline or any adrenergic drug, inflammatory hyperfusion
corticosteroid are now known to exert their ● Can be given via:
effects in the airway vasculature through ○ Metered-dose inhaler (MDI)
genomic and nongenomic actions ○ Tablet
● MOA: ○ Intravenous route
○ Genomic actions: regulation of target
genes → suppress vascular elements of
inflammation and angiogenesis

Inhalants for Asthma Control

Anticholinergics Ipratropium bromide
Aclidinium
Tiotropium
Umeclidinium

Anti inflammatory drugs

Cromolyn Cromolyn

Glucocorticoids (corticosteroids) Beclomethasone

Budesonide
Flunisolide
Fluticasone

● Methylprednisolone - IV/ oral ● Dexamethasone- IV/oral

● Hydrocortisone- IV ● Prednisone- Oral

● NOTE: Inhaled glucocorticoids are not helpful in treating a severe asthmatic attack because it may tak 1
to 4 weeks for an ICS (inhaled corticosteroids) to reach its full effect. (For rapid effect: use
corticosteroids in IV form)
6. CROMOLYN
● Used for prophylactic treatment of ● Can be administered
bronchial asthma ○ Intranasally (metered spray)
● MOA: inhibits release of histamine and ○ Oral inhalation (MDI or nebulizer)
other inflammatory mediators from mast ● Side effects: post nasal drip, irritation of
cells → prevents asthma attack nose and throat, cough
● Adverse Reactions: anaphylaxis, DOB

NURSING INTERVENTIONS
● Advise patients to gargle after using inhaled corticosteroids to avoid oral thrush or fungal infections
● Take note of the common side effects of each medications so you can educate your patients on what
symptoms to expect after giving the medication
● Proper patient education is a must at all times so as to lessen anxiety and also to establish good rapport