Drug	Brand Name	Formulation and Dosage
Beclomethasone dipropionate HFA	QVAR	MDI: 40 mcg/puff and 80 mcg/puff Adults ≥12 yr: 40-80 mcg twice daily,^* or 40-160 mcg twice daily^† Children ≥5 yr: 40-80 mcg twice daily

Budesonide Pulmicort DPI: 200 mcg/actuation Turbuhaler Adults: 200-400 mcg bid,^† 200-400 mcg bid,^† 400-800 mcg bid^‡^§ Children ≥6 yr: 200 mcg bid Pulmicort DPI: 90 mcg/actuation, 180 mcg/actuation Flexhaler Adults: 180-360 mcg bid usual dose range, 720 mcg bid maximum Children ≥6 yr: 180 mcg bid usual dose, 360 mcg bid maximum Pulmicort SVN: 0.25 mg/2 mL, 0.5 mg/2 mL, 1 mg/ml Respules Children 1-8 yr: 0.5 mg total dose given once daily, or twice daily in divided doses;^*^† 1 mg given as 0.5 mg bid or once daily^§ Budesonide and formoterol fumarate HFA Symbicort MDI: Adults ≥12 yr: 80 mcg budesonide with 4.5 mcg formoterol/actuation, 2 puffs bid; and 160 mcg budisonide with 4.5 mcg formoterol/actuation, 2 puffs bid Maximum daily dose: 640 mcg budisonide and 18 mcg formoterol Flunisolide hemihydrate HFA Aerospan MDI: 80 mcg/puff Adults ≥12 yr: 2 puffs bid, adults no more than 4 puffs daily Children 6-11 yr: 1 puff daily, no more than 2 puffs daily Flunisolide AeroBid, AeroBid-M MDI: 250 mcg/puff Adults and children ≥6 yr: 2 puffs bid, adults no more than 4 puffs daily Children ≤15 yr: no more than 2 puffs daily Fluticasone propionate Flovent HFA MDI: 44 mcg/puff, 110 mcg/puff, 220 mcg/puff Adults ≥12 yr: 88 mcg bid,^* 88-220 mcg bid,^† or 880 mcg bid^§ Children 4-11 yr: 88 mcg bid Flovent Diskus DPI: 50 mcg, 100 mcg, 250 mcg Adults: 100 mcg bid^*100-250 mcg bid,^† 1000 mcg bid^§ Children 4-11 yr; 50 mcg twice daily Fluticasone propionate/salmeterol Advair Diskus DPI: 100 mcg fluticasone/50 mcg salmeterol, 250 mcg fluticasone/50 mcg propionate/salmeterol, or 500 mcg fluticasone/50 mcg salmeterol salmeterol Adults and children ≥12 yr: 100 mcg fluticasone/50 mcg salmeterol, 1 inhalation twice daily, about 12 hr apart (starting dose if not currently on inhaled corticosteroids) Maximum recommended dose 500 mcg fluticasone/50 mcg salmeterol twice daily Children ≥4 yr: 100 mcg fluticasone/50 mcg salmeterol, 1 inhalation twice daily, about 12 hr apart (for those who are symptomatic while taking an inhaled corticosteroid) Advair HFA MDI: 45 mcg fluticasone/21 mcg salmeterol, 115 mcg fluticasone/21 mcg salmeterol, or 230 mcg fluticasone/21 mcg salmeterol salmeterol, Adults and children ≥12 yr: 2 inhalations twice daily, about 12 hr apart Mometasone furoate Asmanex DPI: 220 mcg^‡ actuation, 110 mcg actuation for children 4-11 Twisthaler Adults and children ≥12 yr: 220-440 mcg daily,^† 220-440 mcg daily,^* 480-880 mcg daily^§ Triamcinolone acetonide Azmacort MDI: 75 mcg/puff Adults ≥12 yr: 2 puffs tid or qid Children ≥6 yr: 1-2 puffs tid or qid

bid, twice daily; qid, four times daily; tid, three times daily.

* Detailed prescribing information should be obtained from the manufacturer’s package insert.

Modified from Gardenhire DS: Rau’s Respiratory care pharmacology, ed 7, St Louis, 2008, Mosby.

The patient who is using any of these medications must gargle and rinse out his or her mouth after each use. If not, the patient runs the risk of developing a fungal infection of the mouth and throat. Note that there are now two inhaled medications (Advair and Symbicort) that combine a corticosteroid and a long-acting beta agonist (LABA).

Note: While past Written Registry Examinations have included a question concerning nonsteroidal antiinflammatory drugs (NSAIDs), they are not included in the current detailed content outline. They are include here for the sake of completeness. There are several different types of over-the-counter medications. None is as powerful an antiinflammatory as the corticosteroid drugs. Note the other clinical uses of acetylsalicylic acid and ibuprofen:

• Acetylsalicylic acid (e.g., Bayer aspirin): antiinflammatory, mild analgesia, antipyretic, blocks platelet aggregation (clot formation)

• Ibuprofen (Advil, Motrin): antiinflammatory, mild analgesia, antipyretic

• Antihistamine (Claritin): antiinflammatory

b. Cromolyn sodium

1. Recommend the use of cromolyn sodium (ELE code: IIIG4b) [Difficulty: ELE: R, Ap, An]

Cromolyn sodium (Intal) and nedrocromil sodium (Tilade) are indicated to prevent an asthma attack. They accomplish this by coating the mast cells found in the airways so that they do not degranulate and rupture. Without pretreatment, the mast cells of asthmatic patients would rupture when exposed to immunoglobulin E (IgE) from their allergen(s). This mast cell rupture would result in the spilling of leukotriene agents, histamine, and other chemical mediators that cause the bronchospasm, airway edema, and increased airway secretions of an asthma attack.

2. Administer the prescribed medication (Code: IIIC3, IIID5a, IIID5b) [Difficulty: ELE: R, Ap; WRE: An]

When cromolyn sodium, or nedrocromil sodium, is inhaled at least 1 week before exposure to the allergen, the asthmatic reaction is prevented or reduced. Cromolyn was first made available through a dry powder inhaler and is now only available by metered dose inhaler or small volume nebulizer (SVN). Nedrocromil sodium is similar to cromolyn in its use and effects. It is available in a metered dose inhaler. See Table 9-4 for detailed information on both medications.

TABLE 9-4 Inhaled Nonsteroidal Antiasthma Agents ^*

Drug	Brand Name	Formulation and Dosage
CROMOLYN-LIKE (MAST CELL STABILIZERS)
Cromolyn sodium^†	Intal	MDI: 800 mcg/actuation
		Adults and children ≥5 yr: 2 inhalations 4 times daily
		SVN: 20 mg/amp or 20 mg/vial
		Adults and children ≥2 yr: 20 mg inhaled 4 times daily
	Nasalcrom	Spray: 40 mg/mL (4%), gives 5.2 mg of drug
	Nasalcrom	Adults and children ≥2 yr: 1 spray each nostril, 3-6 times daily every 4-6 hr
Nedocromil sodium	Tilade	MDI: 1.75 mg/actuation
Nedocromil sodium	Tilade	Adults and children ≥6 yr: 2 inhalations 4 times daily
ANTILEUKOTRIENES
Montelukast	Singulair	Tablets: 10 mg, 4 mg, and 5 mg cherry-flavored chewable; 4 mg packet of granules
		Adults and children ≥15 yr: one 10 mg tablet daily in evening
		Children 6-14 yr: one 5 mg chewable tablet daily
		Children 2-5 years: one 4 mg chewable tablet or one 4 mg packet of granules daily
		Children 6-23 months: one 4 mg packet of granules daily
Zafirlukast	Accolate	Tablets: 10 and 20 mg
		Adults and children ≥12 yr: 20 mg (1 tablet) twice daily, without food
		Children 5-11 yr: 10 mg twice daily
Zileuton	Zyflo	Tablets: 600 mg
Zileuton	Zyflo CR	Adults and children ≥12 yr: one 600 mg tablet 4 times a day
MONOCLONAL ANTIBODY
Omalizumab	Xolair	Adults and children ≥12 yr: subcutaneous injection every 4 weeks; dose dependent on patient’s weight and serum IgE level

* Detailed prescribing information should be obtained from the manufacturer’s package insert.

† Note: Cromolyn sodium is also available in an oral concentrate giving 100 mg in 5 mL (Gastrocrom) for treatment of systemic mastocytosis, and as an ophthalmic 4% solution (Opticrom, 40 mg/mL) for treatment of vernal keratoconjunctivitis.

Modified from Gardenhire DS: Rail’s Respiratory care pharmacology, ed 7, St Louis 2008, Mosby.

It is very important to understand that both drugs are taken for prophylactic purposes to prevent an asthma attack. They are contraindicated during an asthma attack. A patient experiencing acute bronchospasm should be treated with a fast sympathomimetic bronchodilator, as previously discussed.

c. Recommend the use of leukotriene modifiers (ELE code: IIIG4b) [Difficulty: ELE: R, Ap, An]

Leukotrienes are chemicals found in mast cells that are released during an asthma attack. These released leukotriene chemicals stimulate bronchospasm, airway edema, and increased airway secretions. The leukotriene-modifier (also called leukotriene antagonists) medications work to reduce the number of leukotriene chemicals that are released or to block the effect of leukotrienes on the airways. By accomplishing this, the patient’s asthma symptoms are reduced or eliminated. See Table 9-4 for detailed information on all four medications in this group.

As with cromolyn sodium or nedrocromil sodium, it is very important to understand that all of these drugs are taken for prophylactic purposes to prevent an asthma attack. They are contraindicated during an asthma attack. A patient experiencing acute bronchospasm should be treated with a fast-onset sympathomimetic bronchodilator (SABA), as previously discussed.

4. Mucolytics or proteolytic agents

a. Acetylcysteine

1. Recommend the use of acetylcysteine (ELE code: IIIG4c) [Difficulty: ELE: R, Ap, An]

N-Acetylcysteine/acetylcysteine/NAC (Mucomyst, Mucosil) is a mucolytic drug that has been widely used for many years with patients who have thick (viscous) mucus or mucus plugs. However, its use for the mycolytic effect is now controversial and some authors have advocated for the discontinuation of its clinical use. In the past, the NBRC has included questions where acetylcysteine (Mucomyst) would be indicated as a mucolytic.

Know that there are two clinical concerns with this medication. Acetylcysteine has a bad odor (rotten eggs) that may lead to nausea and vomiting in some patients. Of greater concern is the stimulation of bronchospasm in some asthmatic patients. Therefore it is wise to pretreat these patients with an aerosolized sympathomimetic bronchodilator before acetylcysteine is nebulized. Any fast-onset bronchodilator can be used in the usual dose. Because of the lack of proven clinical effectiveness and the noted hazards, acetylcysteine is no longer recommended in patients with cystic fibrosis. It is still used with chronic bronchitis patients as long as the noted precautions are taken.

2. Administer the prescribed medication (Code: IIIC3, IIID5a) [Difficulty: ELE: R, Ap; WRE: An]

Mucomyst is usually administered with a small volume nebulizer (SVN) or with intermittent positive-pressure breathing (IPPB). Most adult patients are given up to 3 to 5 mL of the 20% solution or up to 6 to 10 mL of the 10% solution. The 20% solution is often diluted with an equal volume of normal saline solution. Direct instillation of 1 to 2 mL of the drug into the trachea also helps to liquefy secretions. The manufacturer recommends that all medication in a vial be used within 96 hours or discarded. It should be stored in the refrigerator. A slightly purple color is commonly seen after the vial has been opened, but it can still be used safely. See Table 9-5 for specific information.

TABLE 9-5 Inhaled Mucoactive Agents^*

b. RhDNAse

1. Recommend the use of RhDNAse (ELE code: IIIG4c) [Difficulty: ELE: R, Ap, An]

Dornase alfa (Pulmozyme; the NBRC refers to this drug as recombinant human deoxyribonuclease [RhDNAse]) is a proteolytic drug that has been approved for use in the treatment of patients with cystic fibrosis. It works by breaking up strands of DNA found in the secretions of these patients with a pulmonary infection.

2. Administer the prescribed medication (Code: IIIC3, IIID5a) [Difficulty: ELE: R, Ap; WRE: An]

Usually a single daily dose of 2.5 mL of solution (containing 2.5 mg of dornase alfa) is inhaled by SVN. Store the drug in a refrigerator, and protect it from strong light. It has no serious side effects. See Table 9-5 for detailed information.

c. Hypertonic saline

1. Recommend the use of hypertonic saline (ELE code: IIIG4c) [Difficulty: ELE: R, Ap, An]

The various saline solutions (and sterile water) are known collectively as “bland” aerosols, because they have no direct pharmacologic effect on the lungs and airways. When they are inhaled as aerosols, however, a vagal nerve–mediated reflex causes the bronchial/submucosal glands to release more watery secretions. Therefore a saline aerosol is commonly used to help liquefy secretions and induce a patient to expel sputum. Recent clinical experience has shown hypertonic saline to be an effective mucolytic in cystic fibrosis patients.

2. Administer the prescribed medication (Code: IIIC3, IIID5a) [Difficulty: ELE: R, Ap; WRE: An]

The various saline solutions are given through an SVN or IPPB treatment or, more commonly, mixed with a bronchodilator medication. See Table 9-5 and Box 9-2 for information on the various saline solutions.

BOX 9-2 Saline Solutions Used as Mucolytics

HYPOTONIC SALINE SOLUTION, 0.45% SALINE

Direct instillation into the airway: Same as with normal saline solution.

Aerosol: Same as with normal saline solution; many practitioners use this concentration in ultrasonic nebulizers.

Miscellaneous: Particles tend to shrink because of evaporation, which results in smaller particles than nebulized that are closer to isotonic; impaction is more likely in the smaller airways.

HYPERTONIC SALINE SOLUTION, 1.8%-10% SALINE

Aerosol: Some practitioners use a large-reservoir nebulizer with a heater to generate the aerosol. Hypertonic saline solution is most commonly used to induce a cough and sputum sample for cytologic studies (e.g., lung cancer) or for fungal or mycobacteria (e.g., tuberculosis) culture. It should not be used for a general bacterial culture because the high salt concentration inhibits the growth of most bacteria. Hypertonic saline has also been found useful as a mucolytic in cystic fibrosis patients.

Miscellaneous: Particles tend to enlarge because of the absorption of water vapor, which results in larger particles than nebulized that are closer to isotonic; impaction is more likely in the upper airway. This concentration is the most likely to cause bronchospasm in asthma patients because it is the furthest from isotonic and, therefore, the most irritating. It may be necessary to pretreat the patient with a short-acting beta-agonist (SABA) bronchodilator.

d. Observe the patient for signs of changes in sputum characteristics (ELE code: IIIE5a) [Difficulty: ELE: R, Ap, An]

The respiratory therapist should objectively evaluate the patient’s cough and sputum production before and after a mucolytic has been administered. This will provide evidence of the medication’s effectiveness. See Chapter 1 for further discussion and Table 1-13 for sputum characteristics.

5. Diuretics

a. Recommend the adjustment of fluid balance (Code: IIIG1d) [Difficulty: ELE: R, Ap; WRE: An]

A patient who is fluid overloaded or has congestive heart failure and pulmonary edema will often exhibit the following signs: peripheral edema, jugular vein distension, crackles for breath sounds, cyanosis, tachycardia, and hypotension. Arterial blood gas results will show hypoxemia. A chest radiograph will show an enlarged heart and pulmonary infiltrates. Shortness of breath is the most common symptom.

Treatment of the patient will include fluid restriction and diuresis to rapidly decrease the patient’s fluid volume. Review Box 1-3 for normal fluid intake and output values.

b. Recommend use of diuretics (Code: IIIG4i) [Difficulty: ELE: R, Ap; WRE: An]

Diuretics are most commonly indicated in patients who are fluid overloaded or have hypertension. The following are examples of diuretics commonly used to treat these problems:

• Furosemide (Lasix)

• Bumetanide (Bumex)

• Torsemide (Demadex)

• Chlorothiazide (Diuril)

These are some of the most powerful diuretics in use. They produce a rapid increase in urine output. They basically prevent the kidneys from retaining sodium so that water is excreted. A side effect of their use is a loss of potassium through the kidneys.

Another category of diuretic is used in patients who have an increased intracranial pressure (ICP). The increased ICP is usually attributable to cerebral edema from a head injury. Examples of medications used to treat an increased ICP include the following:

• Mannitol (Osmitrol)

• Sterile urea (Ureaphil, Urevert)

These medications have a large molecular weight and, through osmosis, “pull” fluid from the brain into the bloodstream. Therefore they are sometimes called osmotic diuretics. The medication, after crossing into the kidney, prevents the reabsorption of water and increases urine output.

c. Recommend blood tests to measure the potassium level (Code: IIIE8) [Difficulty: ELE: R, Ap; WRE: An]

If a patient with fluid overload has been give a diuretic such as Lasix, all electrolytes, especially the serum potassium level, should be check regularly. As stated previously, Lasix and related diuretic medications cause the kidneys to excrete potassium in addition to sodium and water. The so-called potassium-sparing electrolytes (e.g., spironolactone [Aldactone], amiloride [Midamor], triamterene [Dyrenium]) can lead to an increased potassium level. (Review Table 1-2 for the normal electrolyte values.)

d. Recommend the adjustment of electrolyte therapy (Code: IIIG1e) [Difficulty: ELE: R, Ap; WRE: An]

The normal value for serum potassium (K⁺) is 3.5 to 5.5 mEq/L. A potassium level of less than 3.5 mEq/L is dangerous because it increases the risk of cardiac arrhythmias. Replacement potassium is needed. It is usually given by the intravenous route because it is faster than when taken orally.

Be prepared to recommend the administration of any electrolyte that is less than the low end of the range. Conversely, be prepared to recommend withholding an electrolyte supplement if the serum level is greater than the upper end of the range.

Exam Hint 9-3 (ELE, WRE)

There will usually be at least one question that regards the use of a diuretic in a patient who is fluid overloaded, and the side effects of using a diuretic. A diuretic drug such as furosemide (Lasix) tends to cause the loss of potassium through the kidneys. Know to check the serum potassium level. Remember that the normal potassium level is 3.5 to 5.5 mEq/L. If the patient has the signs of dangerous hypokalemia (see Chapter 1), know to recommend that replacement potassium be given.

6. Recommend the use of sedatives (Code: IIIG4f, IIIG1c) [Difficulty: ELE: R, Ap; WRE: An]

Sedatives are medications that affect the brain to induce calming in a patient who can be either simply anxious or very agitated and uncooperative. A patient would be given a sedative in the following situations: (1) when he or she is struggling against a necessary intubation or the mechanical ventilator, thus worsening his or her condition; (2) when he or she is displaying self-destructive behavior because of a drug reaction; and (3) before a medical procedure, for so-called conscious sedation. The effects on the patient are dose related. Low to moderate doses calm the patient, and higher doses induce sleep. Three different groupings of these types of medications exist. The most widely used are the benzodiazepines, because they have fewer side effects and fewer drug interactions and are less likely to cause addiction than are the barbiturate drugs. The benzodiazepine agents can be pharmacologically reversed. The barbiturates are widely used during general anesthesia to induce sleep rapidly. Commonly used examples of the sedative agents include the following:

• Benzodiazepine minor tranquilizers: midazolam (Versed), diazepam (Valium), lorazepam (Ativan), chlordiazepoxide (Librium), alprazolam (Xanax), triazolam (Halcion), flurazepam (Dalmane)

• Nonbarbiturate sedative-hypnotics: meprobamate (Miltown), glutethimide (Doriden), chloral hydrate (Noctec)

• Barbiturate sedative-hypnotics: pentobarbital sodium (Nembutal), secobarbital sodium (Seconal), phenobarbital (Luminol), thiopental sodium (Pentothal)

The benzodiazepine antagonist drug flumazenil (Romazicon) is indicated in the reversal of benzodiazepine agents such as Valium and Librium. Unconscious patients usually awaken quickly once the proper dose of flumazenil is given. Monitor the patient for signs of seizure activity related to the rapid reversal of the benzodiazepine medication. The patient should be observed for 2 hours in case resedation occurs. In this case, flumazenil can be readministered.

7. Recommend the use of analgesics (Code: IIIG4g) [Difficulty: ELE: R, Ap; WRE: An]

Analgesics are medications that control or block pain after an injury or a surgical procedure. Morphine or similar narcotic-type analgesic drugs are indicated to control moderate to severe pain. Morphine also is indicated to treat the pain of a myocardial infarction and to produce vasodilation in the patient with pulmonary edema. Additionally, pain-relieving agents, when given in large enough doses, will sedate or induce sleep. The patient who is both in pain and agitated may be treated with a combination of an analgesic and a sedative (e.g., moderate doses of morphine and diazepam). The two drugs potentiate each other. The physician may instead decide to give the patient a larger dose of morphine rather than both drug types. Examples of commonly used analgesics include the following:

• Morphine sulfate (Duramorph) injection; Oramorph SR, tablets

• Tylenol with codeine tablets

• Oxycodone (Percocet, OxyContin)

• Hydrocodone (Vicodin)

• Hydromorphone (Dilaudid)

• Meperidine (Demerol)

• Propoxyphene (Darvon)

Patients receiving sedatives or analgesics, or both, must be closely monitored. Each type of medication can cause respiratory center depression if given in great enough doses. The patient may hypoventilate and even experience apnea and death. It is especially important to monitor a patient with COPD who is given morphine for the off-label management of dyspnea. Narcotic analgesic agents (e.g., morphine) and some other analgesic medications can become habit forming or addictive if used for a prolonged period.

The narcotic antagonist drug naloxone (Narcan) counteracts the effects of narcotic agents, such as morphine, heroin, and codeine. Narcan does not reverse benzodiazepine or barbiturate drugs. Remember that the patient who was given an accidental overdose of morphine to control pain will feel pain again when Narcan is administered.

Exam Hint 9-4 (ELE, WRE)

There is usually a question about recommending a drug for pain control. If the patient has severe pain from trauma or surgery, recommend morphine sulfate or a similar narcotic analgesic agent. Remember that too much narcotic can cause apnea. Narcan is the reversing agent for a narcotic overdose.

8. Recommend the use of neuromuscular blocking agents (Code: IIIG4h, IIIG1c) [Difficulty: ELE: R, Ap; WRE: An]

The NBRC may use the terms “paralytic agents” and “muscle relaxants” when describing medications that cause a medically induced paralysis. It would be more correct to call these medications neuromuscular blocking agents (NMBAs). They work by blocking nerve transmission from reaching skeletal (voluntary) muscles; and complete paralysis follows. They are most commonly used as part of balanced anesthesia before major thoracic or abdominal surgery. These drugs also are used in the intensive care unit to stop a patient from fighting against an intubation or to prevent the patient from struggling against the mechanical ventilator. All of these agents are given intravenously and act rapidly. Obviously, in all these cases, the patient stops breathing and must receive mechanical ventilation. Examples of the commonly used neuromuscular blocking agents include the following:

• Depolarizing blocker: succinylcholine chloride (Anectine, Quelicin)

• Nondepolarizing blockers: pancuronium bromide (Pavulon; preferred), vecuronium bromide (Norcuron), gallamine triethiodide (Flaxedil), atracurium besylate (Tracrium)

The nondepolarizing blockers (e.g., Pavulon) are preferred for their longer duration of action. Although all these agents induce complete paralysis of all voluntary muscles, they have little or no effect on the involuntary muscles or autonomic nervous system. Some patients may have a minor, passing change in heart rate and blood pressure. Remember that these patients are able to hear, are able to feel pain, and are completely awake and alert to their surroundings. Care must be taken to sedate the patient for anxiety and give analgesics for pain. Talk to the patient normally, and move the patient periodically to prevent pressure sores.

The nondepolarizing neuromuscular blocking agents can be reversed so that the patient can breathe and move again. These intravenous medications include neostigmine bromide (Prostigmin; preferred) and edrophonium (Tensilon). It should be noted that these reversing agents cause an outpouring of oral and bronchial secretions. Atropine is given to prevent this. The reversing agents have no effect on the depolarizing neuromuscular blocker succinylcholine chloride. Patients given this drug usually regain movement within 15 minutes after the medication is stopped.

9. Recommend the use of surfactants (Code: IIIG4j) [Difficulty: ELE: R, Ap; WRE: An]

Surfactant has been approved for the prevention or treatment of infant respiratory distress syndrome (RDS) in premature neonates. These neonates have immature lungs that lack natural surfactant. As a result, atelectasis develops. These three surfactant agents have been approved for instillation into the airways to treat this problem and are widely used:

1. Beractant (Survanta)

2. Poractant alfa (Curosurf)

3. Calfactant (Infasurf)

Dosages for all of the medications are based on the infant’s weight. Once one of these medications is instilled into the neonate’s airways, be prepared to make rapid changes in the mechanical ventilator settings. This is because the lungs will rapidly become more compliant. The set pressure will need to be reduced so that the neonate is not overventilated, resulting in barotrauma. In addition, the oxygen percentage can usually be rapidly reduced.

10. Antimicrobials

a. Recommend the use of antimicrobials (e.g., antibiotics) (Code: IIIG4e) [Difficulty: ELE: R, Ap; WRE: An]

The terms antimicrobial, antiinfective, and antibiotic refer to natural or synthetic chemicals that are toxic to bacteria and other microorganisms. Table 9-6 lists the most commonly found respiratory tract pathogens. See Table 9-7 for a summary of the most common respiratory tract pathogens and the antimicrobial agents used against them. Table 9-8 lists specific information on the four currently approved aerosolized antimicrobial agents given by respiratory therapists and likely to be tested by the NBRC. They are discussed below. Be aware that other systemic antimicrobial medications have been given by aerosol despite not having FDA approval.

TABLE 9-6 Common Respiratory Pathogens in Approximate Order of Frequency

TABLE 9-7 Classification of Antibiotic Agents Commonly Used Against Pulmonary Infections

TABLE 9-8 Inhaled Antimicrobial Agents^*

b. Administer the prescribed medication (Code: IIIC3, IIID5a, IIID5b) [Difficulty: ELE: R, Ap; WRE: An]

1. Antibacterial agent: tobramycin

Tobramycin (TOBI) is used to control chronic pulmonary infection with the gram-negative bacteria Pseudomonas aeruginosa. It has been approved for use in children 6 years and older with cystic fibrosis. TOBI is taken through the PARI LC Plus small volume nebulizer. No other medications are to be mixed with the TOBI in the nebulizer. The currently approved treatment course involves the drug being taken for 28 days. The patient then discontinues the medication for 28 days. This treatment cycle has been shown to control the infection without antibiotic resistance developing.

2. Antiviral agent: zanamivir and ribavirin

Zanamivir (Relenza) is approved for the treatment of influenza in adults and children older than 5 years of age. To be effective, Relenza must be started within the first 2 days of symptoms and continued for 5 days. If taken early enough in the course of the infection, the patient’s symptoms should be reduced and the course of the infection shortened. Relenza is available in a multidose dry powder inhaler (DPI) packet. The medication packet is loaded into the Diskhaler delivery device for inhalation (see Figure 8-18).

Ribavirin (Virazole) is most commonly used in the treatment of infants and young children who have bronchiolitis or pneumonia from the respiratory syncytial virus (RSV). Patients requiring treatment for their condition usually are very sick and have complicating factors such as prematurity or cardiopulmonary disease. They require the treatment course of 3 to 7 days of nebulization of the drug for 12 to 18 hours per day. Only the SPAG II (small particle aerosol generator) can be used for the procedure. This is because it is specifically designed to nebulize the 1- to 2-μm size particles necessary for alveoli penetration so that it can kill the virus. Virazole is also known to be effective against influenza types A and B and the herpes simplex virus. Because of the risk of side effects to health care providers, a scavenging system must be used with Vibrazole to ensure that none of the particles escape into room air.

3. Antiprotozoal agent: pentamidine isethionate

Pentamidine isethionate (NebuPent) has been approved for the prophylactic treatment of the fungal organism Pneumocystis carinii. Patients with impaired immune systems, such as those with acquired immunodeficiency syndrome (AIDS), are most likely to suffer from Pneumocystis carinii pneumonia (PCP). (Note: This may also be called Pneumocystis jiroveci pneumonia [PJP].) Currently, these patients are given a single 300-mg dose of NebuPent mixed with 6 mL of sterile water once every 4 weeks through the Respirgard II small volume nebulizer. This unit also features an expiratory scavenging filter to prevent any droplets from entering the room air (see Figure 8-15). (The AeroTech II unit may also be used to deliver NebuPent.)

Some patients must be pretreated with an inhaled bronchodilator to prevent bronchospasm before the NebuPent is inhaled. Do not mix the two medications in the Respirgard II or use the Respirgard II for any medication other than NebuPent. Mixing NebuPent with normal saline or a bronchodilator can result in a precipitation of the medications. When given by the inhalation route, there are few systemic side effects. There is also an intramuscular or intravenous form of pentamidine called Pentam 300. Bactrim (trimethoprim and sulfamethoxazole) is preferred over systemic pentamidine because there are fewer and less serious side effects.

Exam Hint 9-5 (ELE, WRE)

There is usually one question that considers the need for an antimicrobial medication to treat a pulmonary infection. Know these antimicrobial agents and what they are used to treat:

• Penicillin (e.g., penicillin G, ampicillin) to treat gram-positive bacteria

• Gentamicin (Garamycin) to treat gram-negative bacteria

• Aerosolized tobramycin (TOBI) to treat Pseudomonas pneumonia in children with cystic fibrosis

• Aerosolized pentamidine isethionate (NebuPent) for prophylactic treatment of Pneumocystis carinii

• Aerosolized ribavirin (Vibrazole) to treat respiratory syncytial virus (RSV) in young children

• Isoniazid (INH) to treat Mycobacterium tuberculosis (TB)

11. Recommend the use of vaccines (e.g., Pneumovax, influenza) (Code: IIIG4k) [Difficulty: ELE: R; WRE: Ap]

See Chapter 2 for the discussion on vaccination to prevent avian flu, severe acute respiratory syndrome (SARS) from the coronavirus, and Streptococcus pneumoniae.

12. Recommend the use of cardiovascular drugs (e.g., ACLS protocol agents) (Code: IIIG4d) [Difficulty: ELE: R, Ap; WRE: An]

See Chapter 11 for the discussion on drugs that may be used during CPR efforts.

Exam Hint 9-6 (ELE)

Expect several questions that require the respiratory therapist to recommend the use of medications in the classes discussed previously. Know the indications for these groups of medications and the main medications in each group.

MODULE C

Drug dosage calculations (math review)

Exam Hint 9-7 (ELE, WRE)

The NBRC examination content outline does not specifically list drug dosage calculations. However, previous Entry Level and Written Registry Examinations have included one calculation.

The problems are easier to solve by remembering the following:

1. One milliliter (1 mL) or 1 cubic centimeter (1 cc) of water = 1 gram (g) of mass.

2. Most drug doses are listed in milligrams instead of grams. Convert grams to milligrams by moving the decimal point three places to the right (the same as multiplying by 1000). For example, 0.5 g equals 500 mg.

3. Know how to interconvert fractions, decimal fractions, and percentages. For example: 1 : 100 = 1/100 = 0.01 = 1%.

One common way to solve any drug dosage calculation is by creating a proportional problem. The drug concentration must be converted into a fractional form. The proportional problem can then be set up to solve for the unknown amount of active ingredient. For example:

1. How much active ingredient would be in 0.5 mL of adrenaline?

A 1% (1 : 100) drug concentration means that there is 1 part of active ingredient in 100 parts of the solution, or 1 mL or 1 g of active ingredient in 100 mL or 100 g of the solution. This can be set up in the following proportion:

100x = 0.5 mL (Divide both sides of the equation by 100.)x = 0.005 mL = 0.005 g = 5 mg of active ingredient

2. How much active ingredient would be in 0.25 mL of Alupent? (Alupent is 5.0% active ingredient.)

A 5% drug concentration means that there are 5 parts of active ingredient in 100 parts of the solution, or 5 mL or 5 g of active ingredient in 100 mL or 100 g of the solution. This can be set up in the following proportion:

100x = 1.25 mL (Divide both sides of the equation by 100.)x = 0.0125 mL = 0.0125 g = 12.5 mg of active ingredient

Thus the amount of active ingredient can be calculated if the drug concentration is given in either a fractional or a percentage form.

The next two examples deal with calculating the volume of medication solution needed to deliver a desired amount of active ingredient. With these types of questions, it is necessary to convert to consistent units, usually converting grams to milligrams.

3. How much 0.5% Proventil would be needed to give a patient 2.5 mg of active ingredient by SVN?

A 0.5% (1 : 200) drug concentration means that there is 1 part of active ingredient in 200 parts of the solution, or 1 mL or 1 g of active ingredient in 200 mL or 200 g of the solution. This converts to 1000 mg/200 mL. Set up the following proportion:

1000 x = 500 mL (Divide both sides of the equation by 1000.)x = 0.5 mL of Proventil should be given.

4. How much 4% Xylocaine would be needed to give a patient 100 mg of active ingredient by handheld nebulizer before a bronchoscopy?

A 4% drug concentration means that 4 parts of active ingredient are in 100 parts of the solution, or 4 mL or 4 g of active ingredient in 100 mL or 100 g of the solution. This converts to 4000 mg/100 mL. Set up the following proportion:

4000x = 10,000 mL (Divide both sides of the equation by 4000.)x = 2.5 mL of Xylocaine should be given.

Thus the volume of medication solution needed to deliver a given amount of active ingredient can be calculated if the drug concentration is given in either a fractional or a percentage form.

MODULE D

Respiratory care plan

1. Analyze the available information to determine the patient’s pathophysiologic state (Code: IIIH1) [Difficulty: ELE: R, Ap; WRE: An]

The respiratory therapist should be able to determine when the patient is having cardiopulmonary problems that could require an inhaled medication. Review, if needed, information presented in Chapters 1, 3, 4, and 5 that deals with bedside assessment, blood gases, pulmonary function tests, and advanced cardiopulmonary monitoring.

2. Determine the appropriateness of the prescribed respiratory care plan and recommend modifications when indicated

a. Determine the appropriateness of the prescribed therapy and goals for the identified pathophysiologic state (Code: IIIH3) [Difficulty: ELE: R, Ap; WRE: An]

b. Review the planned therapy to establish the therapeutic plan (Code: IIIH2a) [Difficulty: ELE: R, Ap; WRE: An]

Patients with stable asthma or COPD will often require several inhaled medications including bronchodilators and corticosteroids. The patient with life-threatening status asthmaticus will require multiple treatment procedures. These are likely to include many of the following: admission into the intensive care unit, supplemental oxygen, monitoring of vital signs, electrocardiogram monitoring, serial arterial blood gases, continuous pulse oximetry, periodic bedside spirometry, heliox, intubation, and/or mechanical ventilation. Inhaled medications for this patient can include short-acting beta agonists (SABA) given hourly or continuously and parasympathomimetic medications. Systemic medications will likely include a corticosteroid and antileukotriene agent. Lastly, a theophylline agent may be added. The goal is to resolve the asthmatic crisis. After the patient has been stabilized, long-term care can be planned. This is likely to include long-acting beta agonists (LABA), an inhaled corticosteroid, and other preventative agents. If the patient has a pulmonary infection, the correct antimicrobial drug should be used to treat the problem.

c. Recommend changes in the therapeutic plan when indicated (Code: IIIH4) [Difficulty: ELE: R, Ap; WRE: An]

This chapter discusses medications that can be used to help treat many commonly seen cardiopulmonary conditions. When these medications are used properly for the appropriate patient condition, there is a good chance of recovery. The patient’s vital signs and other clinical indicators will improve. The patient will report feeling better.

However, if the patient’s signs and symptoms do not indicate improvement, be prepared to recommend a change in the medication. This may involve changing a dose or switching to another medication. Stop any medication to which the patient is having an allergic reaction. Tell the patient’s physician about the problem, and ask for further orders.

d. Conduct disease management education programs (Code: IIIK4) [Difficulty: ELE: R, Ap; WRE: An]

The most recent Written Registry Exams have included questions that relate to the management and education of the patient with asthma. It also is recommended that the management and education of a patient with COPD be studied. The bibliography includes information on standard references on these two subjects.

e. Terminate the treatment or procedure based on the patient’s response to therapy (Code: IIIF1) [Difficulty: ELE: R, Ap; WRE: An]

As mentioned earlier, Box 9-1 lists the side effects most often seen with adrenergic (sympathomimetic) bronchodilators. The most serious problem is tachycardia. In some cases, patients may have cardiac arrhythmias. A common clinical guideline requests the treatment be discontinued if the patient’s heart rate increases by more than 20% during the treatment. The patient should be monitored to confirm that the heart rate slows. Chart the information, and notify the nurse.

Exam Hint 9-8 (ELE, WRE)

Expect to see a question in which the decision has to be made to stop the bronchodilator treatment because the patient’s heart rate increases by more than 20% from the baseline. For example, stop the treatment in the following situation: The pretreatment heart rate is 100 beats/min and the heart rate during the treatment increases to greater than 120 beats/minute.

f. Recommend discontinuing the treatment or procedure based on the patient’s response (Code: IIIG1i) [Difficulty: ELE: R, Ap; WRE: An]

The physician discontinues treatment for one of two reasons. First, the patient has recovered and no longer needs a medication. Some asthma patients may fully recover and not need any medications. However, it is more common to determine the right medications to control the condition so that the patient does not need to use rescue medications. Patients with emphysema or chronic bronchitis (COPD), or both, are likely to always need medications.

Second, the patient has a serious adverse reaction to the medication. As discussed earlier, Box 9-1 lists the adverse reactions to the adrenergic (sympathomimetic) bronchodilators. Repeated episodes of tachycardia or cardiac arrhythmias, or both, could lead to the physician discontinuing their use.