RESPIRATORY MEDICATIONS

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CHAPTER 14 RESPIRATORY MEDICATIONS

PRETEST QUESTIONS

Answer the pretest questions before studying the chapter. This will help you determine your strong and weak areas in the material covered.

1. With which of the following lung disorders would acetylcysteine (Mucomyst) be indicated?

1. Emphysema
2. Bronchiectasis
3. Cystic fibrosis
4. Pulmonary edema
A. 1 and 2 only
B. 2 and 3 only
C. 3 and 4 only
D. 1, 2, and 3 only

2. A patient with glottic edema after extubation is in mild respiratory distress. Which of the following medications would be of benefit in this situation?

A. Cromolyn sodium
B. Succinylcholine (Anectine)
C. Racemic epinephrine
D. Pentamidine

3. You are having difficulty intubating a combative patient in the emergency department. The respiratory therapist should recommend the delivery of which drug to facilitate intubation?

A. Succinylcholine (Anectine)
B. Cromolyn sodium
C. Atropine sulfate
D. Epinephrine

4. Which of the following airway disorders may be successfully treated with dexamethasone (Decadron)?

1. Asthma
2. Glottic edema
3. Pulmonary edema
A. 1 only
B. 2 only
C. 1 and 2 only
D. 2 and 3 only

See answers and rationales at the back of the text.

REVIEW

I. CLASSIFICATION OF RESPIRATORY MEDICATIONS

CRT Exam Content Matrix: IIIC3,IIID5a, IIIF2h4, IIIG2b, IIIG4a,b,c,e-k

RRT Exam Content Matrix: IIIC3, IIID5a, IIIG2b, IIIG4b-h

A. Diluents
1. Normal saline solution (0.9% NaCl)
a. Used to dilute bronchodilating agents
b. Used to dilute secretions for improved expectoration. Often instilled through ET tubes and tracheostomy tubes, 3 to 5 mL at a time.
2. Hypotonic saline solution (0.4% NaCl)
a. Used in ultrasonic nebulizers because smaller particles are produced as result of lower concentration.
b. More stable than sterile water
3. Hypertonic saline solution (1.8% NaCl)
a. Larger aerosol particles are produced because of the higher concentration of the solution.
b. Used to stimulate coughing and induce sputum because it is irritating to the airway.
4. Sterile distilled water
a. Used to dilute other medications
b. Used to hydrate secretions, thereby decreasing the viscosity for easier expectoration
c. Used to humidify dry gases
B. Mucolytics: Drugs that break the sputum down chemically for more effective expectoration.
1. Acetylcysteine (Mucomyst)
a. Available in 10% or 20% solutions
b. It breaks the disulfide bonds in the sputum, thus decreasing the sputum’s viscosity.
c. Often used with bronchodilating agents because a common side effect of acetylcysteine is bronchospasm.
d. Should be used in treating patients with thick secretions that are difficult to mobilize
e. Often used in treating patients with cystic fibrosis or bronchiectasis
f. May be nebulized (1 to 3 mL, three to four times daily) or instilled directly into the trachea
g. If bronchospasm occurs, stop the treatment immediately and administer a bronchodilating agent.
h. Is irritating to mucosal tissues. The patient should rinse mouth after treatment.
2. Dornase alfa (Pulmozyme, RhDNase)
a. Used most commonly in patients with cystic fibrosis or other lung conditions in which thick, tenacious sputum is present
b. Must be kept refrigerated and protected from light
c. Do not nebulize in combination with other drugs. Administering a bronchodilator before dornase alfa may help increase the deposition of the drug.
3. Sodium bicarbonate (2% NaHCO3)
a. Increases the pH of the sputum, thereby decreasing its viscosity
b. May be used to improve the mucolytic actions of acetylcysteine
c. Dosage: 2 to 5 mL via aerosol or 2 to 10 mL instilled directly into the trachea every 4 to 8 h

C. Sympathomimetic Bronchodilators

image Exam Note

These medications stimulate one or more of the following adrenergic receptors.

Receptor Location Response
Alpha Mucosal blood vessels, bronchial smooth muscle Vasoconstriction, bronchoconstriction
Beta1 Heart muscle Increased heart rate and cardiac output, arrhythmias
Beta2 Bronchial smooth muscle, peripheral mucosal blood vessels, CNS, and peripheral limb muscles Bronchodilation, vasodilation, nervousness (CNS), tingling in fingers

image Exam Note

The ideal bronchodilator is one that is a pure adrenergic beta2 receptor stimulator.

1. Epinephrine hydrochloride (Adrenalin Chloride, Sus-Phrine)
a. Stimulates all three adrenergic receptors
b. Duration of action is 30 min to 2 h
c. Used to stimulate the heart; not commonly used as a bronchodilator
d. Adverse effects
(1) Increased heart rate
(2) Hypertension
(3) Anxiety
e. Dosage: aerosol, 0.1 to 0.5 mL (1 : 100 solution) in 3 to 5 mL of diluent
2. Racemic epinephrine (microNefrin, Vaponefrin)
a. Stimulates all three receptors but most strongly the beta1 receptor
b. Duration of action is 30 min to 2 h
c. Used to decrease mucosal edema and inflammation after extubation or in pediatric patients with croup
d. Has milder effects than epinephrine (half-strength)
e. Dosage: aerosol, 0.2 to 0.5 mL in 3 to 5 mL of diluent every 3 to 4 h
3. Metaproterenol (Alupent, Metaprel)
a. Very minor beta1 and mild beta2 receptor stimulator
b. Duration of action is 4 to 6 h
c. Used to decrease airway resistance
d. Adverse effects
(1) Mild cardiac effects
(2) Mild CNS effects
e. Dosage: 0.1 to 0.3 mL in 3 to 5 mL of diluent every 4 h
4. Terbutaline sulfate (Brethine, Bricanyl)
a. Very minor beta1 and moderate beta2 receptor stimulator
b. Duration of action is 3 to 7 h
c. Used to decrease airway resistance
d. Adverse effects
(1) Mild cardiac effects
(2) Mild CNS effects
e. Dosage: 200 mg/puff via MDI every 4 to 6 h
5. Albuterol (Proventil, Ventolin)
a. Mild beta1 and strong beta2 receptor stimulator
b. Duration of action is 4 to 6 h
c. Used to decrease airway resistance
d. Adverse effects
(1) Mild cardiac effects
(2) Mild CNS effects
(3) Nausea
(4) Tremors
e. Dosage: 2.5 to 5 mg, every 4 to 6 h
6. Levalbuterol (Xopenex)
a. Selective beta2 receptor stimulator
b. Chemically similar to albuterol. The (R)-enantiomer of albuterol, which has the most bronchodilating effects, was isolated and purified for use and called levalbuterol.
c. Lower dosage required than for albuterol: 0.63 mg to 1.25 mg three times per day
d. Action of up to 8 h
e. First line drug for patients with COPD or asthma
f. Mild cardiac side effects, nervousness, and tremors but less than with albuterol
7. Salmeterol (Serevent)
a. It is a long-acting beta agonist with stronger beta2 than beta1 effects and is available as a DPI preparation used twice daily.
b. Duration of action: up to 12 h (1 h onset of action)
c. Used to decrease airway resistance
d. Adverse effects
(1) Tachycardia
(2) Hypertension
(3) Nausea
(4) Tremors
8. Formoterol (Foradil)
a. It is a long-acting beta agonist with stronger beta2 than beta1 effects and is available as a DPI preparation used twice a day.
b. Indications and adverse effects are the same as for salmeterol.
c. Duration of action is 12 h with a peak effect at 30 to 60 min compared with 3 to 5 h for salmeterol.
9. Arformoterol (Brovana)
a. It is a long-acting beta agonist with stronger beta2 than beta1 effects and is available as a liquid aerosolized preparation used twice a day with a small volume nebulizer.
b. The indications, side effects, and onset and duration of action are similar to formoterol.
D. Parasympatholytic Bronchodilators
1. Atropine sulfate
a. An anticholinergic drug; it blocks the cholinergic constricting influences on the airway and potentiates the adrenergic influences (beta2 stimulation), resulting in bronchodilation.
b. Also inhibits secretion production and increases secretion viscosity.

image Exam Note

There is more potential for mucus plugging in patients with thick secretions who are given intravenous atropine. Given as an aerosol, atropine has little effect on lung secretions but may dry out the oral mucosa.

c. Used to decrease airway resistance, congestion, and cardiac arrhythmias

image Ipratropium bromide is faster acting, longer lasting, and exhibits fewer side effects than atropine.

d. Adverse effects
(1) Increased secretion viscosity
(2) Dry mouth
(3) CNS stimulation
e. Dosage: 1 mg in 3 to 5 mL of diluent, every 4 to 6 h
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