Respiratory Drugs

ANTITUSSIVE

·         It suppresses the cough reflex by acting on medulla’s cough-control center.

·         Indications:

o    Nonproductive cough, cough that interferes with sleep or daily activities

·         Contraindications:   

o     Hypersensitivity, pregnancy, breastfeeding, used cautiously in patients with benign prostatic hyperplasia, debilitation, thoracotomy, laparotomy, or a history of drug or alcohol abuse

Narcotics ( Opioid)	Nonnarcotics( Nonopioid)
codeine phosphate, codeine sulfate (Codeine®)	benzonatate (Tessalon®)
hydrocodone (Hycodan®)	dextromethorpan (Robitussin DM®)
	diphenhydramine (Benadryl®, Benylin®)

Side Effects:

·         Dizziness, drowsiness

·         GI irritation, nausea

·         Dry mouth

·         Constipation

·         Respiratory depression

Nursing Considerations:

ü  Assess breath sounds, cough characteristics, frequency and bronchial secretions.

ü  Maintain patent airway, suction if necessary.

ü  Maintain a fluid intake of 2-3 L a day for adults.

ü  Instruct patient if cough lasts longer than 1 week, and a fever or rash occurs, notify the physician.

ü  Place the patient with the head of the bed elevated.

ü  Stress the importance of smoking cessation, and maintain adequate environmental humidity.

ü  Avoid alcohol and other over-the-counter products.

ü  Avoid administration to the patient using narcotics, sedative hypnotics, barbiturates, or anti-depressants, due to CNS depression can occur.

ü  Advise the patient that possible dependency can occur if an opioid drug is used.

ü  Encourage compliance with the therapy, and take the drug as prescribed.

ü  Stress the need of follow up care and repeat laboratory test if necessary to monitor condition.

EXPECTORANTS

(bronchomucotropic agents)

·         Used to assist in the removal of secretions or exudates from the trachea, bronchi, or lungs.

·          It acts by liquefying viscid mucus or mucopurulent exudates

·         Indications:

o    Common cold, upper respiratory tract infections, minor bronchial irritations, bronchitis, influenza, sinusitis, emphysema, bronchial asthma, relieve dry hacking cough

·         Contraindications:   

o    Hypersensitivity, used cautiously with ineffective cough reflex or respiratory insufficiency, pregnancy, breastfeeding

Example:

guaifenesin (Humibid® L.A., Liquibid®, Mucinex®, Robitussin®, Tussin®)

Side effects:

·         Drowsiness

·         GI irritations

·         Skin rash

·         Oropharyngeal irritation

Nursing Considerations:

ü  Take medication with a full glass of water to enhance effects of expectorants by making secretions less viscous.

ü  Inform health care provider before taking any over-the-counter or herbal medications.

ü  Instruct the patient not to take guaifenesin for a persistent cough associated with smoking, asthma, emphysema, or excessive secretions.

MUCOLYTICS

·         Reduce the viscosity of the bronchial secretions by liquefying and loosening thick mucous secretions by cleaving disulphide bonds cross-linking mucus glycoprotein molecules.

·          Indications:

o    Treat abnormal, viscid, or thick and hard mucus, antidote for acetaminophen overdose

·         Contraindications:   

o    Hypersensitivity; cautiously used in elderly, debilitated, pregnant, or breastfeeding, and patients with asthma

Example:

acetylcysteine (Mucomyst®)

dornase alfa (Pulmozyme®)

Side effects:

·         Nausea, vomiting

·         Drowsiness

·         Stomatitis

·         Rhinorhhea

·         Chest tightness

Nursing Considerations:

ü  Assess the respiratory status before and after each dose.

ü  Administer acetylcysteine (Mucomyst) by nebulizer because this drug reacts with iron, copper, and rubber; frequently monitor the patient’s nebulizer equipment for reactive effects.

ü  Avoid contamination of the solution and refrigerate an opened vial. Discard opened vials after 4 days.

ü  Provide chest physiotherapy, postural drainage and encourage coughing and deep breathing to facilitate removal of respiratory secretions.

ü  Instruct the patient to gargle after administration of the drug to relieve unpleasant odor and dryness.

ü  Keep suction equipment available for emergency use.

ü  Seek medical help if condition worsens.

DECONGESTANTS

·         Used to reduce the swelling of the nasal passages by stimulating the alpha-adrenergic receptors, thus producing vasoconstriction of the capillaries within the nasal mucosa.

·         Indications:

o    Common cold, hay fever, sinusitis, allergic rhinitis, cough, congestion associated with rhinitis

·         Contraindications:   

o    Hypersensitivity, used cautiously patients with hypertension, cardiac disease, hyperthyroidism, or diabetes mellitus

Example:

oxymetazoline hydrochloride ( Afrin®)

phenylephrine hydrochloride (Neo-Synephrine®)

phenylproponalamine hydrochloride (Dimetapp®)

pseudoephedrine hydrochloride (Sudafed®)

xylometazoline hydrochloride (Otrivin®)

Side effects:

·         Nervousness	·         Nausea, vomiting
·         Restlessness	·         Hypertension
·         Tachycardia	·         Hyperglycemia
·         Blurred vision

Nursing Considerations:

ü  Monitor for cardiac dysrhythmias, and blood glucose levels.

ü  Avoid over-the-counter products, and herbal remedies.

ü  Inform the patient that the drug may interfere with sleep, therefore take the drug a few hours before bedtime.

ü  Do not break, cut, crush, or chew the capsule or tablet; take the drug in its complete form.

ü  Teach the patient how to administer topical decongestant properly in the lateral head-low position for drops; in the upright position for sprays.

ü  Instruct patient the importance of limiting the use of nasal sprays or drops, and not to exceed the recommended amount, frequency, duration of topical decongestants.

ü  Topical administration may cause rebound congestion if used for more than 5 days in a row.

ü  Encourage use of humidifier if nasal dryness occurs.

CORTICOSTEROIDS

·         Act as anti-inflammatory agents which inhibit the production of cytokines, leukotrines, and prostaglandins, the recruitment of eosinophils, and the release of other inflammatory mediators.

·         It works by decreasing the number and activity of inflammatory cells in the respiratory tract while inhibiting bronchoconstriction.

·         Indications:

o    Chronic asthma, chronic bronchitis, allergic rhinitis, and prophylactic treatment for exercise-induced asthma

·         Contraindications:   

o    Hypersensitivity, acute bronchospasm, status asthmaticus, acute episodes of asthma; cautiously used in patients with compromised immune systems, glaucoma, kidney disease, liver disease, convulsive disorders, and diabetes.

Example: (Inhaled corticosteroids)
beclomethasone dipropionate (Vabceril®, Beclovent®)
triamcinolone (Azmacort®)	(Oral corticosteroids)
fluticasone (Flonase®, Flovent®)	prednisolone
flunisolide ( AeroBid®)	prednisone
( I.V. corticosteroids)
methylprednisolone sodium	(DepMedalone®,Depojec®t)
hydrocortisone sodium succinate	(Cortef® ,Hydrocortone®)

(See also Endocrine System Drugs)

Adverse Reactions:

·         Throat irritation

·         Hoarseness

·         Cough

·         Fungal infection of the mouth and throat

·         Vertigo

·         Headache

·         Hyperglycemia

·        

Oral/ IV

Osteoporosis

·         Immunosuppression

Nursing Considerations:

ü  Assess the respiratory condition regularly and assess peak flow readings before starting treatment

ü  Monitor the patient on signs & symptoms of oropharyngeal fungal infection.

ü  Instruct patient to rinse mouth with water after dose.

ü  Monitor the growth especially in children receiving systemic agents or higher doses of inhaled agents. Use the lowest effective dose to reduce the risk of adverse reactions.

ü  For elderly patients, suggest ways to prevent osteoporosis such as increased calcium intake and weight-bearing exercise.

ü  Instruct the patient to follow the prescribed administration and dosage of the drug.

ü  Give oral doses with food to prevent GI irritation.

ü  Teach the patient on how to administer the inhaled form properly via inhalation with the use of a spacer.

ü  Recognize early signs & symptoms of adrenal insufficiency such as fatigue, muscle weakness, fever, anorexia, dyspnea, and fainting; if these occur notify the physician.

ü  Do not stop the drug abruptly.

General Instructions for Metered-Dose Inhalers:

o    Shake the inhaler well, with the canister in place, for 5 to 10 seconds immediately after use.

o    Remove the cap and hold the inhaler system upright.

o    Tilt your head back slight and breathe out to the end of a normal breath.

o    Hold the inhaler on preferred method use:  holding the lips around the mouthpiece, holding the inhaler away from the mouth, and use spacer or extender (Spacers are useful for all patients, especially young children and older adults).

o    Position the mouthpiece 2 to 3 finger-widths from open mouth or use spacer.

o    Activate the inhaler, press down the inhaler to release the medicine, while taking a slow, deep breath for 3 to 5 seconds.

o    Hold the breath for about 10 seconds to allow the medicine goes deeply into the lungs and exhale slowly.

o    If more than one inhalation is required, wait about 1 minute between inhalations. Two minutes are allowed between inhalations for metaproterenol (see manufacturer’s directions for specific times).

o    Rinse or gargle the mouth after each dose to relieve dry mouth and throat irritation and prevent fungal infection.

o    If applicable, rinse the extender and mouthpiece daily in warm water and store them away from heat.

o    To monitor the amount of drug remaining in the canister, test the canister by placing it in a container of water (i.e. a full canister sinks; an empty canister floats).

o    Remember if two different inhaled medications are prescribed, and one of the medications contains glucocorticoids (corticosteroid), administer the bronchodilator first and the corticosteroids second, wait 5 minutes following the bronchodilator before inhaling the corticosteroids.