Chapter 37 Bronchodilators and Respiratory Drugs

A. Diseases of the Lower Respiratory Tract * COPD * Asthma * Emphysema * Chronic bronchitis B. Bronchial Asthma * Recurrent and reversible shortness of breath * Occurs when the airways of the lungs become narrow as a result of: * Bronchospasms * Inflammation of the bronchial mucosa * Edema of the bronchial mucosa * Production of viscid mucus * Alveolar ducts/alveoli remain open, but airflow to them is obstructed * Symptoms * Wheezing * Difficulty breathing C. Asthma * Three categories * Allergic * Idiopathic.

* Mixed allergic-idiopathic * Status asthmaticus * Prolonged asthma attack that does not respond to typical drug therapy * May last several minutes to hours * Medical emergency D. Chronic Bronchitis * Continuous inflammation of the bronchi and bronchioles * Often occurs as a result of prolonged exposure to bronchial irritants E. Emphysema * Air spaces enlarge as a result of the destruction of alveolar walls * The surface area where gas exchange takes place is reduced * Effective respiration is impaired F.

Drugs Used to Treat Asthma * Long-term control * Leukotriene receptor antagonists * Inhaled steroids * Long-acting beta2-agonists * Quick relief * Intravenous systemic corticosteroids * Short-acting inhaled beta2-agonists G. Bronchodilators and Respiratory Drugs * Bronchodilators * Beta-adrenergic agonists * Xanthine derivatives * Anticholinergics * Leukotriene receptor antagonists * Corticosteroids H. Bronchodilators: Beta-Agonists * Large group, sympathomimetics * Used during acute phase of asthmatic attacks.

* Quickly reduce airway constriction and restore normal airflow * Stimulate beta2-adrenergic receptors throughout the lungs Three types * Nonselective adrenergics * Stimulate alpha, beta1 (cardiac), and beta2 (respiratory) receptors * Example: epinephrine * Nonselective beta-adrenergics * Stimulate both beta1 and beta2 receptors * Example: metaproterenol (Alupent) * Selective beta2 drugs * Stimulate only beta2 receptors * Example: albuterol (Proventil, others) Beta-Agonists: Mechanism of Action * Begins at the specific receptor stimulated * Ends with dilation of the airways.

* Activation of beta2 receptors activates cyclic adenosine monophosphate (cAMP), which relaxes smooth muscle in the airway and results in bronchial dilation and increased airflow Beta-Agonists: Indications * Relief of bronchospasm related to asthma, bronchitis, and other pulmonary diseases * Used in treatment and prevention of acute attacks * Used in hypotension and shock * Used to produce uterine relaxation to prevent premature labor Beta-Agonists: Adverse Effects * Alpha and beta (epinephrine) * Insomnia * Restlessness * Anorexia * Vascular headache * Hyperglycemia.

* Tremor * Cardiac stimulation * Beta1 and beta2 (metaproterenol) * Cardiac stimulation * Tremor * Anginal pain * Vascular headache * Hypotension * Beta2 (albuterol) * Hypotension OR hypertension * Vascular headache * Tremor Beta-Agonists: Nursing Implications * Encourage patients to take measures that promote a generally good state of health so as to prevent, relieve, or decrease symptoms of COPD * Avoid exposure to conditions that precipitate bronchospasm (allergens, smoking, stress, air pollutants) * Adequate fluid intake * Compliance with medical treatment.

* Avoid excessive fatigue, heat, extremes in temperature, caffeine * Encourage patients to get prompt treatment for flu or other illnesses, and to get vaccinated against pneumonia or flu * Encourage patients to always check with their physician before taking any other medication, including over-the-counter medications * Perform a thorough assessment before beginning therapy, including: * Skin color * Baseline vital signs * Respirations (should be between 12 and 24 breaths/min) * Respiratory assessment, including pulse oximetry * Sputum production * Allergies * History of respiratory problems.

* Other medications * Teach patients to take bronchodilators exactly as prescribed * Ensure that patients know how to use inhalers and MDIs, and have patients demonstrate use of the devices * Monitor for adverse effects * Monitor for therapeutic effects * Decreased dyspnea * Decreased wheezing, restlessness, and anxiety * Improved respiratory patterns with return to normal rate and quality * Improved activity tolerance * Decreased symptoms and increased ease of breathing *.

Beta-agonist derivatives * Albuterol, if used too frequently, loses its beta2-specific actions at larger doses * As a result, beta1 receptors are stimulated, causing nausea, increased anxiety, palpitations, tremors, and increased heart rate * Beta-agonist derivatives (cont’d) * Ensure that patients take medications exactly as prescribed, with no omissions or double doses *.

Inform patients to report insomnia, jitteriness, restlessness, palpitations, chest pain, or any change in symptoms Inhalers: Patient Education * For any inhaler prescribed, ensure that the patient is able to self-administer the medication * Provide demonstration and return demonstration.

* Ensure that the patient knows the correct time intervals for inhalers * Provide a spacer if the patient has difficulty coordinating breathing with inhaler activation * Ensure that the patient knows how to keep track of the number of doses in the inhaler device I. Anticholinergics * Ipratropium bromide (Atrovent) and tiotropium (Spiriva) * Slow and prolonged action * Used to prevent bronchoconstriction * NOT used for acute asthma exacerbations! Anticholinergics: Mechanism of Action.

* Acetylcholine (ACh) causes bronchial constriction and narrowing of the airways * Anticholinergics bind to the ACh receptors, preventing ACh from binding * Result: bronchoconstriction is prevented, airways dilate Anticholinergics: Adverse Effects * Dry mouth or throat * Nasal congestion * Heart palpitations * Gastrointestinal distress * Headache * Coughing * Anxiety * No known drug interactions J. Bronchodilators: Xanthine Derivatives * Plant alkaloids: caffeine, theobromine, and theophylline * Only theophylline is used as a bronchodilator * Synthetic xanthines: aminophylline and dyphilline Xanthine Derivatives: Mechanism of Action.

* Increase levels of energy-producing cAMP * This is done competitively inhibiting phosphodiesterase (PDE), the enzyme that breaks down cAMP * Result: decreased cAMP levels, smooth muscle relaxation, bronchodilation, and increased airflow Xanthine Derivatives: Drug Effects * Also cause cardiovascular stimulation: increased force of contraction and increased heart rate, resulting in increased cardiac output and increased blood flow to the kidneys (diuretic effect) * Cause bronchodilation by relaxing smooth muscle in the airways * Result: relief of bronchospasm and greater airflow into and out of the lungs * Also cause CNS stimulation.

Xanthine Derivatives: Indications * Dilation of airways in asthmas, chronic bronchitis, and emphysema * Mild to moderate cases of acute asthma * Adjunct drug in the management of COPD * Not used as frequently because of potential for drug interactions and variables related to drug levels in the blood Xanthine Derivatives: Adverse Effects * Nausea, vomiting, anorexia * Gastroesophageal reflux during sleep * Sinus tachycardia, extrasystole, palpitations, ventricular dysrhythmias * Transient increased urination Xanthine Derivatives: Nursing Implications

* Contraindications: history of PUD or GI disorders * Cautious use: cardiac disease * Timed-release preparations should not be crushed or chewed (cause gastric irritation) * Report to physician: * Palpitations * Weakness * Convulsions * Nausea * Dizziness * Vomiting * Chest pain * Be aware of drug interactions with cimetidine, oral contraceptives, allopurinol, certain antibiotics, others K. Leukotriene Receptor Antagonists (LTRAs) * Newer class of asthma medications * Currently available drugs * montelukast (Singulair) * zafirlukast (Accolate) * zileuton (Zyflo).

LRTAs: Mechanism of Action * Leukotrienes are substances released when a trigger, such as cat hair or dust, starts a series of chemical reactions in the body * Leukotrienes cause inflammation, bronchoconstriction, and mucus production * Result: coughing, wheezing, shortness of breath * LRTAs prevent leukotrienes from attaching to receptors on cells in the lungs and in circulation * Inflammation in the lungs is blocked, and asthma symptoms are relieved LRTAs:Drug Effects * By blocking leukotrienes: * Prevent smooth muscle contraction of the bronchial airways * Decrease mucus secretion.

* Prevent vascular permeability * Decrease neutrophil and leukocyte infiltration to the lungs, preventing inflammation LRTAs: Indications * Prophylaxis and chronic treatment of asthma in adults and children older than age 12 * NOT meant for management of acute asthmatic attacks * Montelukast is approved for use in children ages 2 and older, and for treatment of allergic rhinitis LRTAs: Adverse Effects * Zileuton * Headache, dyspepsia, nausea, dizziness, insomnia, liver dysfunction * Zafirlukast * Headache, nausea, diarrhea, liver dysfunction.

* Montelukast has fewer adverse effects LRTAs: Nursing Implications * Ensure that the drug is being used for chronic management of asthma, not acute asthma * Teach the patient the purpose of the therapy * Improvement should be seen in about 1 week * Advise patients to check with physician before taking over-the-counter or prescribed medications—there are many drug interactions * Assess liver function before beginning therapy * Teach patient to take medications every night on a continuous schedule, even if symptoms improve L. Corticosteroids * Antiinflammatory properties.

* Used for chronic asthma * Do not relieve symptoms of acute asthmatic attacks * Oral or inhaled forms * Inhaled forms reduce systemic effects * May take several weeks before full effects are seen Corticosteroids: Mechanism of Action * Stabilize membranes of cells that release harmful bronchoconstricting substances * These cells are called leukocytes, or white blood cells * Increase responsiveness of bronchial smooth muscle to beta-adrenergic stimulation Inhaled Corticosteroids * beclomethasone dipropionate (Beclovent, Vanceril) * triamcinolone acetonide (Azmacort).

* dexamethasone sodium phosphate (Decadron Phosphate Respihaler) * fluticasone (Flovent, Flonase) * Others Inhaled Corticosteroids: Indications * Treatment of bronchospastic disorders that are not controlled by conventional bronchodilators * NOT considered first-line drugs for management of acute asthmatic attacks or status asthmaticus Inhaled Corticosteroids: Adverse Effects * Pharyngeal irritation * Coughing * Dry mouth * Oral fungal infections * Systemic effects are rare because low doses are used for inhalation therapy Inhaled Corticosteroids: Nursing Implications.

* Contraindicated in patients with psychosis, fungal infections, AIDS, TB * Teach patients to gargle and rinse the mouth with lukewarm water afterward to prevent the development of oral fungal infections * If a beta-agonist bronchodilator and corticosteroid inhaler are both ordered, the bronchodilator should be used several minutes before the corticosteroid to provide bronchodilation before administration of the corticosteroid *.

Teach patients to monitor disease with a peak flow meter * Encourage use of a spacer device to ensure successful inhalations * Teach patient how to keep inhalers and nebulizer equipment clean after uses NURSING PROCESS Assessment The net drug effect of beta agonists, xanthine derivatives, anticholinergics, LTRAs, and corticosteroids is improved airflow in airway passages and increased oxygen supply. Cautions, contraindications, and drug interactions (discussed previously) should be assessed before these drugs are administered.

In a thorough assessment of patients receiving any of the respiratory drugs, the patient’s skin color, temperature, respiration rate (which should be more than 12 and less than 24 breaths/min), respiration depth and rhythm, breath sounds, blood pressure, and pulse should be monitored as needed.

The nurse should also determine if the patient is having problems with cough, dyspnea, orthopnea, or hypoxia, or has other signs or symptoms of respiratory distress. The patient should also be assessed for the presence of any of the following: sternal retractions, cyanosis, restlessness, activity intolerance, cardiac irregularities, palpitations, hypertension, tachycardia, and use of accessory muscles to breathe. The anterior-posterior diameter of the thorax should be determined and pulse oximetry reading noted to determine oxygen saturation levels.

The patient should be assessed for a history of allergies, and any specific allergens (e. g. , dust, pollen, mold, mildew, nuts, or other foods) should be noted. If a cough is present, its character, frequency, and presence or absence of sputum should be noted. The color of the sputum should also be noted. A complete medication history should be obtained that includes information about prescription and over-the-counter (OTC) drugs, herbal products, alternative therapies, use of nebulizers and/or humidifiers, use of a home air conditioner, and intactness of the heating and air conditioning system.

The characteristics of any respiratory symptoms (e. g. , seasonally induced, exercise or stress induced) and any family history of respiratory diseases should be noted. Any environmental exposures as well as precipitating and alleviating factors for any respiratory symptoms and/or disease processes should be identified. An excellent resource for the assessment of asthma can be found online at http://www. asthma. com/asthma_control_test. html. Smoking habits should also be assessed, because smoking exacerbates respiratory symptoms and nicotine interacts with many respiratory drugs.

Cardiac status may be compromised due to respiratory distress; thus the patient’s blood pressure, pulse rate, heart sounds, and electrocardiogram, if ordered, need to be assessed closely. Blood gas analysis may be indicated with attention to the patient’s pH, oxygen, carbon dioxide, and serum bicarbonate levels. The nail beds should be assessed for abnormalities (e. g. , clubbing, cyanosis), and the area around the lips should be examined for cyanotic changes. Restlessness is often the first sign of hypoxia, so assessing for this as needed is critical, and it should be reported to the prescriber if present.

If chest radiographs, scans, or magnetic resonance images have been ordered, the findings should be reviewed. Along with a physical assessment, a psychosocial and emotional assessment is needed, because anxiety, stress, and fear may only further compromise the patient’s respiratory status and oxygen levels. The nurse should be sure to note the age of the patient, because drug sensitivity is increased in elderly and pediatric patients. ————————————————- LIFE SPAN CONSIDERATIONS: The Elderly Patient ————————————————-

————————————————- Xanthine Derivatives ————————————————- •Xanthine derivatives should be administered cautiously with careful monitoring in the elderly because sensitivity to these drugs is increased in this patient population due to decreased drug metabolism. ————————————————- •Elderly patients should be assessed for signs and symptoms of xanthine toxicity, which include nausea, vomiting, restlessness, insomnia, irritability, and tremors.

Discriminating the cause of restlessness (e. g. , hypoxia versus drug toxicity) is important to patient safety. ————————————————- •Elderly patients should never chew or crush sustained-released dosage forms and remain aware of drug interactions, especially interactions with other asthma-related drugs/bronchodilators. Advise the elderly to avoid omitting and/or doubling up on doses. If a dose is missed, the prescriber should be contacted for further instructions. ————————————————-

•Monitoring of serum levels during follow-up visits is important to avoid possible toxicity and ensure therapeutic blood levels. ————————————————- •Lower dosages may be necessary initially in the elderly, not only because of their increased sensitivity to the drug but also because of the possibility of decreased liver and renal functioning. Close monitoring for adverse effects and toxicity should be part of everyday therapy, and palpitations and increased blood pressure (from cardiovascular and central nervous system stimulation) should be noted and reported.

For the beta agonists, cautions, contraindications, and drug interactions associated with these drugs have been discussed previously, and a general overview of the required respiratory assessment has been provided; however, the need to assess for allergies to the fluorocarbon propellant in inhaled dosage forms should also be emphasized. The patient’s intake of caffeine (e. g. , chocolate, tea, coffee, candy, and sodas) and use of OTC medications containing caffeine (e. g. , appetite suppressants, pain relievers) should be assessed.

The intake of caffeine is important to determine, because of its sympathomimetic effects and possible potentiation of adverse effects associated with albuterol and other beta agonists (e. g. , tachycardia and hypertension from cardiac stimulation, vascular headache and tremors from CNS stimulation). Educational level and readiness to learn should also be assessed to aid in preparing patient education, such as instructions about the use of MDIs, nebulizers, and other dosage forms. Respiratory anticholinergic drugs and their cautions, contraindications, and drug interactions have been discussed previously.

Assessments for patients taking these drugs should include those mentioned earlier as well as assessment for any history of GI disorders, heart palpitations, benign prostatic hyperplasia (because of drug-induced urinary retention), or glaucoma (because of drug-induced increase in intraocular pressure). Patients with an allergy to soy lecithin, peanut oils, peanuts, soybeans, or other legumes have shown a higher risk of allergy to the anticholinergics, and the patient should be assessed for such allergies before these drugs are given.

Ipratropium and its aerosol forms have been associated with bronchospasms, and thus the patient should be assessed for any preexisting problems with the use of MDIs. If a combination product containing both ipratropium and albuterol is prescribed, the patient needs assessment appropriate to the use of both of these drugs. Assessment for patients prescribed xanthine derivatives (e. g. , theophylline) should include identification of any contraindications, cautions, and drug interactions (see previous discussion).

Cardiovascular and CNS stimulation may occur with these drugs, thus careful cardiac and neurologic assessment is required. GI reflux may also occur with these drugs, so an assessment for bowel patterns and preexisting disease, such as gastroesophageal reflux and/or ulcers, is also important. Results of renal and liver function tests should also be assessed if these are ordered. Baseline urinary patterns must be assessed due to possible transient urinary frequency. A dietary assessment should include questions about consumption of a low-carbohydrate, high-protein diet and intake of charcoal-broiled meat.

These dietary practices may lead to increased theophylline elimination and possibly decreased therapeutic levels of the drugs, whereas a high-carbohydrate, low-protein diet may decrease excretion of the drug and lead to theophylline toxicity. Caffeine-containing foods, beverages, prescription drugs, OTC drugs, and herbals should be noted because of possible cardiovascular and CNS stimulation. It is important to remember that many OTC and prescription antimigraine preparations contain caffeine.

With corticosteroids (also known as glucocorticoids), baseline assessment of vital signs, breath sounds, and heart sounds should be performed. Assessment for underlying adrenal disorders is important because of the adrenal suppression that occurs with the use of these medications. Age should be noted, because corticosteroids may be problematic for the pediatric patient if long-term therapy and/or high dosage amounts are used. The systemic impact on the pediatric patient is suppressed growth (see pharmacology section for further discussion).

As with the other drugs in this chapter, awareness of basic information about these drugs, especially their action, is very important for safe use and prevention of medication errors. For example, glucocorticoids are used for their antiinflammatory effects, beta agonists and xanthines for their bronchodilating effects, and anticholinergics for their blockage of cholinergic receptors. Knowing what drugs do and why they are used helps to prevent or decrease medication errors and adverse effects. See Chapter 33 for more information on these antiinflammatory adrenal drugs. ————————————————-

PREVENTING MEDICATION ERRORS ————————————————- ————————————————- Oral Ingestion of Capsules for Inhalation Devices ————————————————- ————————————————- Some inhalation products use capsules and a device that pierces the capsules to allow the powdered medication to be inhaled with a special inhaler. Two products, Foradil Aerolizer (formoterol fumarate inhalation powder) and Spiriva HandiHaler (tiotropium bromide inhalation powder) contain such capsules.

Even though these capsules are packaged with inhaler devices, they closely resemble oral capsules. The U. S. Food and Drug Administration (FDA) has received reports that the capsules have been taken orally by patients, which can potentially result in adverse effects. If the capsules are swallowed instead of taken using the inhalation device, the medication’s onset of action may be delayed, the efficacy is reduced, and as a result the patient receives inadequate drug delivery. The FDA has taken steps to work with the drug manufacturers to mark the packaging clearly.

Nurses need to be certain to instruct patients on the proper use and correct route of administration for these inhaled drugs to prevent their confusion with oral products. With LTRAs, it is important to assess for contraindications, cautions, and drug interactions. Liver functioning should be determined because of specific concerns about the use of these drugs in patients with altered hepatic function. As with other medications, the elderly are more sensitive to these drugs. The type of asthma attack is also important to note, because these drugs are used more for prevention and long-term treatment.

Omalizumab, a monoclonal antibody antiasthmatic drug, requires additional assessment of known risks associated with certain malignancies. Taking a thorough nursing history will help identify any of these risks, and the information obtained should be documented. Implementation Nursing interventions that apply to patients with respiratory disease processes (e. g. , COPD, asthma, other upper and lower respiratory tract disorders) include patient education and an emphasis on compliance and prevention, in addition to the specific actions related to the prescribed drug therapy.

Measures to implement to prevent, relieve, or decrease the manifestations of the disease should be emphasized to the patient at all times, and the patient’s awareness of specific precipitating and relieving factors should be increased. Bronchodilators and other respiratory drugs should be given exactly as prescribed and by the prescribed route (e. g. , parenterally, orally, by intermittent positive pressure breathing, or by inhalation). The proper method for administering the inhaled forms of these drugs should be demonstrated to the patient, who should provide a return demonstration.

The patient should also be strongly discouraged from taking more than the prescribed dose of the beta agonists, xanthines, and other respiratory drugs because of the excessive cardiac demands related to adverse effects of cardiac and CNS stimulation (hypertension and tachycardia) that may occur. The use of MDIs requires coordination to inhale the medication correctly and to obtain approximately 10% of drug delivery to the lungs. If a second puff of the same drug is ordered, wait 1 to 2 minutes between puffs. If a second type of inhaled drug is ordered, wait 2 to 5 minutes between the medications, or take as prescribed.

Use of a spacer may be indicated to increase the amount of drug delivered. See the Legal and Ethical Principles box for information concerning the environmental hazards associated with MDIs. Dry powder inhalers are small hand-held devices that deliver a specific amount of dry micronized power with each inhaled breath. Their use does not require the same degree of coordination as do MDIs, they deliver about 20% of the drug to the lung, and they have no propellants and as such do not pose problems for the environment. One to two minutes should also be allowed between each puff.

A nebulizer dosage form delivers small amounts of misted droplets of the drug to the lungs through a small mouthpiece or mask. Although a nebulizer may take a longer time to deliver the drug to the lungs than the inhalers, the nebulizer dosage form may be more effective for some patients. See Chapter 10 for more information. Beta agonists should be taken exactly as prescribed. Overdosage may be life-threatening, and so the patient must receive adequate education that emphasizes the need for the proper dosage and frequency.

Oral sustained-released tablets should not be crushed or chewed and should be taken with food to decrease GI upset. Instructions for inhaled dosage forms are presented in Patient Teaching Tips. Before, during, and after therapy with these drugs, it is important to reassess the respiratory status and breath sounds. Anticholinergic drugs used for respiratory diseases (e. g. , ipratropium), should be taken daily as ordered and with appropriate use of the MDI. See Patient Teaching Tips for more information on the administration of these drugs.

It is important to wait from 1 to 2 minutes (or as prescribed) before inhaling the second dose of the drug to allow for maximal lung penetration. Exact instructions should be included in the prescriber’s order for the medication and may vary. Rinsing the mouth with water immediately after use of any inhaled or nebulized drug may help to prevent mucosal irritation and dryness. Xanthine derivatives should also be given exactly as prescribed. If they are to be administered parenterally, the nurse should always determine the correct diluent and rate of administration.

Intravenous infusion pumps should be used to ensure dosage accuracy and help prevent toxicity. Too rapid an infusion may lead to profound hypotension with possible syncope, tachycardia, seizures, and even cardiac arrest. To prevent a sudden increase in drug release and irritating effects on the gastric mucosa, timed-release preparations should not be crushed or chewed. Oral forms should be taken with food to decrease GI upset. Suppository forms of the drug should be refrigerated, and patients should notify the prescriber if rectal burning, itching, or irritation occurs.

The patient should continue to be monitored for respiratory status and improvement in baseline condition during drug therapy. Inhaled corticosteroids (glucocorticoids) should also be used exactly as prescribed, and the patient should be cautioned about overuse. The medication should be taken as ordered every day, regardless of whether the patient is feeling better or not. Often these drugs (e. g. , flunisolide) are used as maintenance drugs and are taken twice daily for maximal response. An inhaled beta2 agonist may be used before the inhaled corticosteroid to provide bronchodilation before administration of the antiinflammatory drug.

The bronchodilator inhaled drug is generally taken 2 to 5 minutes (or as ordered) before the corticosteroid aerosol. All equipment (inhalers or nebulizers) should be kept clean, with filters cleaned and changed (nebulizers), and maintained in good working condition. Use of a spacer may be indicated, especially if success with inhalation is limited. Rinsing of the mouth immediately after use of the inhaler or nebulizer dosage forms of corticosteroids is recommended to help prevent overgrowth of oral fungi and subsequent development of oral candidiasis (thrush).

Pediatric patients may need a prescriber’s order to have these medications on hand at school and during athletic events or physical education. Peak flow meter use is also encouraged to help patients of all ages better regulate their disease. Journaling to record peak flow levels, signs and symptoms of the disease, any improvement, and any adverse effects associated with therapy may be helpful. For pediatric patients, use of systemic forms of corticosteroids is a concern. Specifically, in children the use of systemic forms of these drugs may lead to suppression of the hypothalamic-pituitary-adrenal axis and subsequent growth stunting.

However, the benefits are considerable when compared to the risks. Inhaled forms are often combined with short-term systemic therapy in pediatric patients. The nurse should continue to monitor the patient’s condition during therapy with a focus on the respiratory, cardiac, and central nervous systems. The LTRAs, specifically zileuton, montelukast, and zafirlukast, are given orally. Of most concern are the montelukast chewable tablets, which contain aspartame and approximately 0. 842 mg of phenylamine per 5-mg tablet. Some patients may need to avoid these substances.

Patient education should also emphasize that these drugs are indicated for treatment of chronic, not acute, asthma. These drugs should be taken as ordered and on a continuous schedule, even if symptoms improve. Fluid intake should increase, as with all the respiratory drugs, to help decrease the viscosity of secretions. The monoclonal antibody antiasthmatic drug omalizumab should be taken exactly as ordered. It is given as a subcutaneous injection and requires either instruction in self-injection or frequent visits to the prescriber, nurse, or other health care provider to receive the injection.

This drug is usually given every 2 to 4 weeks. Omalizumab is not indicated for acute asthma attacks and it may be used in conjunction with other acute-acting asthma medications. Evaluation The therapeutic effects of any of the drugs used to improve the control of acute or chronic respiratory diseases and to treat or help prevent respiratory symptoms including the following: a decrease in dyspnea, wheezing, restlessness, and anxiety; improved respiratory patterns with return to normal rate and quality; improved activity tolerance and arterial blood gas levels; improved quality of life; and decreased severity and incidence of respiratory symptoms.

The therapeutic effects of bronchodilators (e. g. , xanthines, beta agonists) include decreased symptoms and increased ease of breathing. Blood levels of theophylline should be between 5 and 15 mcg/mL and should be frequently monitored. Peak flow meters are easy to use and help reveal early decreases in peak flow caused by bronchospasms. They also aid in monitoring treatment effectiveness. Other respiratory drugs should produce the therapeutic effects related to the specific drug.

Adverse effects for which to monitor during therapy include the following: beta agonists and anticholinergics—nausea, vomiting, anorexia, urinary retention, and increased intraocular pressure; xanthenes—nausea, vomiting, anorexia, dyspepsia, and cardiac and CNS stimulation; corticosteroids—adrenocortical insufficiency, increased susceptibility to infection, fluid and electrolyte disturbances, endocrine effects, insomnia, nervousness, seizures, and dermatologic and connective tissue effects, including brittle skin, bone loss, and osteoporosis;

LTRAs—dyspepsia, headaches, nausea, dizziness, and insomnia; monoclonal antibody antiasthmatic drugs—fatigue, joint pain, and pain, swelling, redness, and/or increased warmth at the injection site. ————————————————- PATIENT TEACHING TIPS ————————————————- ————————————————- Beta Agonists ————————————————- •Educate about maintaining healthy living habits.

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