Transcript Advanced Pharmacology Sills 9

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Definitions
Route of Administration
Drug Categories
What do you Recommend
Calculations
Respiratory Care Plan
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Pharmacology
Drug
Medication
Pharmacotherapy
Synergism
Pharmacokinetic Phase
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Time Course and Deposition of a drug in the body
Ionized Drug (will limit systemic absorption)
 Effects local to the airway
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Non-Ionized Drug
 Diffuses across cell membrane into the bloodstream
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Pharmacodynamic Phase
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Mechanism of action
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L/T ratio (Lung availability/Total Systemic
availability ratio)
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Increased ratio indicates more meds delivered to lungs
Toxicology
LD 50
ED50
Therapeutic Index
Tachyphylaxis
Carcinogen
Teratogens
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Onset of Drug Action is Related to Route of
Administration
 IA (Intra-arterial)
 IV (Intravenous)
 IM (Intramuscular)
 Aerosol/Inhalation
 Subcutaneous
 Oral/Gatrointestinal
 Topical
**If no IV is available, use ETT tube next**
ADVANTAGES
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Immediate onset at desired site
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Decreased side effects
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less systemic absorption
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Smaller doses of potent drugs
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Self-Administration
**Only disadvantage is that the delivered doses
are not consistent**
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Wetting Agents or mucolytics
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Surface-active agents (surfactant)
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ACLS Drugs
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Bronchodilators
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Antiinflammatory Agents
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Adrenergic Agents
Inhaled Anticholinergic
Agent
Xanthines
Nonsteroidal
Corticosteroids
Nonsteroidal Antiasthma
Agents
Mucolytics/ Proteolytics
Agents
Saline (Bland)
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Diuretics Agents
Sedatives Agents
Analgesics Agents
Paralytics Agents
Surfactants Agents
Cardiac drugs/ACLS
Antimicrobials,
Antiinfectives,
Antibiotics
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Result in relaxed bronchial smooth muscle
 Adrenergic (Sympathomimetic)
 Most common group of drugs among aerosolized
agents
 Active
 Anticholinergic (Parasympatholytic)
 Passive
 Xanthines (Phosphodiesterase inhibitors)
 Passive
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Sympathomimetic (cyclic 3’5’ AMP)
Anticholinergic (Block the bronchoconstricting
effects of the parasympathetic system)
Xanthines (inhibit breakdown of cyclic 3’5’
AMP)
***Both sympathetic and parasympathetic
receptors are found in the lung***
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Emergency system
Dominate during
great stress
Adrenaline
(epinephrine)
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Alpha
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Vasoconstriction
 Mucosal edema
 Blood vessels of mucus membranes/skeletal muscle
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Beta-1
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Heart
 increased HR
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Beta-2
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Airways
 Dilation of Bronchi
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Smooth muscle
vasoconstriction
 Racemic
epinephrine
 Vaso-pressors
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Inflammation due to increased capillary
permeability=mucosal edema
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Not allergic response
Injury: smoke, fumes, steam
Trauma: Intubation/Extubation
Infection: croup, epiglottitis, bronchiolitis
Bleeding from bronchoscopy
Administered via SVN
 Located
in
the heart
 Tachycardia
 Increased
stoke
volume
 Located
airways
in the
 Bronchodilation
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Neurotransmitter is
norepinephrine
Many names
 Catecholamines
 Noncatecholamines
 Sympathomimetic
amines
 Beta Agonist
Amine is an ammonium derivative;
nitrogen with a hydrogen group
replaced by an organic group
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Catecholamine
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Mixed beta-1 and beta-2 effects
Alpha, and beta-1, and/or beta-2 effects
Non-Catecholamine
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Strong beta-2 specificity
Newer beta agonists
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Acute bronchospasm
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Fast-acting
Rescue agents
Chronic but stable
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Not used to treat acute episodes
Peak response 3-5 hours
**NBRC hint: if the patient is in distress, give them a
SABA via SVN**
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A fast-onset medication (albuterol,
levalbuterol) is used to treat a patient with
acute bronchospasm. A long-duration
medication (salmeterol, formoterol) is used to
treat a patient with chronic, stable
bronchospasm. A vasoconstricting medication
(racemic epinephrine) is used to treat airway
edema or bleeding.
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Tremor*** most frequent
Palpitations, tachycardia
Headache
Increased BP
Nervousness and irritability
Dizziness
Nausea
↓ PaO2 ---Why?
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Worsening V/Q ratio
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Acetylcholine (neurotransmitter)
Binds at the cholinergic receptor
 Results in bronchoconstriction
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Parasympatholytic
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Blocks parasympathetic nervous
system (aka anticholinergics)
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This category is more
effective for treating
COPD patients than
asthma patients
Ipratropium bromide
(Atrovent)
 Tiotropium Bromide
(Spiriva)
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Atropine
Increased HR
 Decreased
secretions
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Glycopyrrolate
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Caffeine
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1st choice for apnea in
babies
Theobromide
Theophylline
***IV/Oral Route
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Bronchodilator
Pulmonary vasodilation
Cardiac Stimulation
Skeletal muscle stimulation (enhanced
diaphragmatic contractility)
CNS stimulation
Diuresis
Narrow therapeutic range (10-15 u/mL)
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Nonsteroidal antiinflammatory drugs
Corticosteroids
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Prophylactic drugs used in the
treatment of asthma
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Mast cell stabilizers
 Prevent degranulation of mast cell
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Anti-leukotrienes (leukotriene modifier)
 Prevent the receptor site from binding to antigen
Mast cell degranulation
Introduction of allergen
Addition of leukotrines
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Acetylcysteine (Mucomyst)
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Always give with a bronchodilator
Dornase Alfa (Pulmozyme)
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Used with CF patients with purulent secretions
Breaks up the strands of DNA in sputum
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Sterile water
Saline
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0.9% is normal saline
>0.9% is considered hypertonic but usually it is a 3-15%
concentration
 Used for sputum inductions (don’t use mucomyst for a
sputum induction!)
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If the patient has edema or hypertension.
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Lasix
Diuril
Edecrin
If the patient has increased ICP
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Mannitol
Ureaphil
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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
K+ level. Remember that the normal K+ level is
3.5 to 5.5 mEq/L. If the patient the signs of
dangerous hypokalemia, know to recommend
that replacement K+ be given.
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Decrease anxiety under a variety of
circumstances
Amnestics (can’t remember)
Induce sleep
Terminate seizures (muscle relaxant)
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Benzodiazepine
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Nonbarbiturate
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Versed, Valium, Xanax
Noctec, Doriden
Barbiturate
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Phenobarbital, Seconal
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Medications that control or block pain after
injury or a surgical procedure
Opioid drugs
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Morphine Sulfate
 Good for decreasing pain for patient on mechanical
ventilation
Codeine Phosphate
 Dilaudid
 Demerol
 Darvon
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***Reverse opioid analgesics with
Naloxone (Narcan)***
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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.
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Can use with combative patients to facilitate
mechanical ventilation
Depolarizing Blocker
Succinylcholine
 Short acting
 Cannot be reversed
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Nondepolarizing Blockers
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Longer acting
Pavulon
Vecruronium Bromide
Flaxedil
Tracrium
 Must
sedate the patient!!
 Must be on the ventilator!!
 Must monitor vital signs!!
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Colfosceril Palmitate (Exosurf)
Beractant (Survanta)
Poractant Alfa (Curosurf)
Calfactant (Infasurf)
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Amiodarone
Beta Blockers
Calcium channel blockers
Calcium chloride
Dobutamine
Dopamine
Digitalis
Levophed
Lidocaine
Decreases ventricular irritability
Treat PVC’s and other arrhythmias
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Procainamide
Propranolol
Nipride
ACLS
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Epinephrine
Vassopressin
Atropine
Sodium Bicarbonate
Magnesium Sulfate
Atropine
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Epinephrine (Adrenaline) is a first-line drug
used in a CPR attempt. It is used during
bradycarida, asystole, and ventricular
fibrillation because it increases the heart rate,
stroke volume, and vasoconstriction to raise
blood pressure. (In addition, it is a
bronchodilator).
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Antimicrobials
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Antibiotics
Antimycobacterials
Antifungals
Antiviral
Antiinfectives
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Pentamidine
 Pneumocystis jiroveci (PCP)
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Ribavirin
 RSV
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Tobramycin
 Pseudomonas aeruginosa in CF patients
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Zanamivir (Relenza)
 Influenza
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Know antimicrobial agents and what they are used
to treat:
 Penicillin to treat gram-positive bacteria
 Gentamicin to treat gram-negative bacteria
 Aerosolized tobramycin to treat Pseudomonas
pneumonia in children with CF
 Aerosolized pentamidine isethionate for
prophylactic treatment of Pneumocystis carinii
 Aerosolized ribavirin to treat RSV in young
children
 Isoniazid (INH) to treat Mycobaterium tuberculosis
 Acute
and Chronic
bronchospasm?
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Bleeding from a bronchoscopy biopsy?
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Inhaled bronchodilators and corticosteroid
drugs have not managed the patient’s problem.
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Status asthmaticus?
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Prophylactic purposes to prevent an asthma
attack
Contraindicated during an asthma attack
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Mucomyst is ordered.
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Average of 3 questions
Acute verses stable bronchospasm
Lasix needs K replacement
RSV or PCP
Premie:
aminophylline or caffeine
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Drug Dilution
Volume and Concentration
Volume of Medication of Deliver Desired
Active Igredient
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How many milligrams are in 5ml of a 4% solution?
Convert % solution to mg/ml
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Multiply % solution valuetimes 10
 2% solution =20 mg/ml
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Divide mg by 10 to get % solution
 5mg/ml=0.5% solution
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4% solution = 40 mg/ml
40 mg/ml x 5 ml=200mg
200mg/10=20% solution
How many milligrams are in 5 ml of a 4% solution?
40mg/mlx5ml=200mg
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You have 15ml of 20% Mucomyst. You want a 15%
solution. How many ml will you have if you dilute it to
achieve this%?
V1 x C1 = V2 x C2
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15 ml x 20% = V2 x 15%
15ml x 200 mg/ml = V2 x 150 mg/ml
3000 mg = V2 x 150 mg/ml
3000 mg/150 mg/ml = V2
20 ml = V2
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How much 1:100 strength Isuprel would be needed to
give a patient 2.5mg of active ingredient?
Change concentration to a fraction
Convert grams to mg (i.e., 1g/100ml=1000mg/100ml)
Set up the equation 1000mg = 2.5mg
100ml
Unknown
 1000mg x (unknown) = 250mg/ml
 Unknown=250mg/ml
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1000mg
 Unknown=0.25ml of Isuprel
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Which one of these drugs would be best to use
to temporarily paralyze a patient to facilitate
tracheal intubation?
a. atropine sulfate
b. succinylcholine (anectine)
c. Midazolam (versed)
d. Pancuronium bromide (Pavulon)
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Which one of these drugs would be best to use
to temporarily paralyze a patient to facilitate
tracheal intubation?
a. atropine sulfate
b. succinylcholine (anectine)
c. Midazolam (versed)
d. Pancuronium bromide (Pavulon)
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A patient has been paralyzed with vecuronium
(Norcuron) and is receiving mechanical
ventilation. Which of the following ventilator
monitoring alarms would be the most
important?
a. low pressure
b. high pressure
c. inspired gas temperature
d. I:E time
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A patient has been paralyzed with vecuronium
(Norcuron) and is receiving mechanical
ventilation. Which of the following ventilator
monitoring alarms would be the most
important?
a. low pressure
b. high pressure
c. inspired gas temperature
d. I:E time
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Which of the following medications would be
most indicated in the treatment of a patient
with large amounts of thick secretions?
a.
b.
c.
d.
Salmeterol
Hypotonic saline
Acetylcysteine
albuterol
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Which of the following medications would be
most indicated in the treatment of a patient
with large amounts of thick secretions?
a.
b.
c.
d.
Salmeterol
Hypotonic saline
Acetylcysteine
albuterol
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While delivering a bronchodilating agent to a
patient using a handheld nebulizer, you note the
pulse increases from 72/min to 88/min over the
first 5 min of therapy. Which of the following is the
most appropriate action to take?
a.
b.
c.
d.
Stop the treatment immediately and notify the physician
Continue the treatment as ordered
Increase the inspiratory pressure for the remainder of the
treatment
Give the remainder of the treatment with saline only

While delivering a bronchodilating agent to a
patient using a handheld nebulizer, you note the
pulse increases from 72/min to 88/min over the
first 5 min of therapy. Which of the following is the
most appropriate action to take?
a.
b.
c.
d.
Stop the treatment immediately and notify the physician
Continue the treatment as ordered
Increase the inspiratory pressure for the remainder of the
treatment
Give the remainder of the treatment with saline only
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After administering a bland aerosol treatment
to a patient, the RT auscultates bilateral
rhonchi. The therapist should recommend
which of the following?
a. discontinue the treatment and initiate IPPB
therapy
b. Encourage the patient to deep breath and
cough
c. initiate bronchodilator therapy
d. discontinue therapy
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After administering a bland aerosol treatment
to a patient, the RT auscultates bilateral
rhonchi. The therapist should recommend
which of the following?
a. discontinue the treatment and initiate IPPB
therapy
b. Encourage the patient to deep breath and
cough
c. initiate bronchodilator therapy
d. discontinue therapy
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You are having difficulty intubating a
combative patient in the emergency
department. The RT should recommend
delivery of which drug to facilitate intubation?
a. Succinylcholine (anectine)
b. cromolyn sodium
c. atropine sulfate
d. epinephrine
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You are having difficulty intubating a
combative patient in the emergency
department. The RT should recommend
delivery of which drug to facilitate intubation?
a. Succinylcholine (anectine)
b. cromolyn sodium
c. atropine sulfate
d. epinephrine
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An RT is called to the ED to assist with the
intubation of an alert, agitated patient in
respiratory failure. Two intubation attempts
were unsuccessful. Which of the following
drugs would best facilitate intubation?
a. nifedipine (Verapamil)
b. lorazepam (Ativan)
c. propranolol (Inderal)
d. nitroprusside (Nipride)

An RT is called to the ED to assist with the
intubation of an alert, agitated patient in
respiratory failure. Two intubation attempts
were unsuccessful. Which of the following
drugs would best facilitate intubation?
a. nifedipine (Verapamil)
b. lorazepam (Ativan)
c. propranolol (Inderal)
d. nitroprusside (Nipride)
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A patient in the ICU has been receiving
mechanical ventilation for 2 weeks. The
sputum has changed from white to green and
sweet smelling. Which of the following should
an RT recommend?
a. antibiotic therapy
b. antiviral therapy
c. antiprotozoan therapy
d. anti-inflammatory therapy
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A patient in the ICU has been receiving
mechanical ventilation for 2 weeks. The
sputum has changed from white to green and
sweet smelling. Which of the following should
an RT recommend?
a. antibiotic therapy
b. antiviral therapy
c. antiprotozoan therapy
d. anti-inflammatory therapy
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Which of the following could be recommended
to reduce systemic arterial blood pressure and
reduce ventricular preload?
a.
b.
c.
d.
Sodium nitroprusside (Nipride)
Dobutamine (Dobutrex)
Dopamine (Intropin)
Propranolol (Inderal)
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Which of the following could be recommended
to reduce systemic arterial blood pressure and
reduce ventricular preload?
a.
b.
c.
d.
Sodium nitroprusside (Nipride)
Dobutamine (Dobutrex)
Dopamine (Intropin)
Propranolol (Inderal)

A 68-year-old man with a history of COPD is
admitted to the hospital for increasing
shortness of breath and a nonproductive
cough. Chest auscultation reveals expiratory
wheezes. Which of the following is the most
appropriate to improve the patient’s clinical
condition?
a. beclomethasone (Vanceril)
b. ipratropium bromide (Atrovent)
c. amoxicillin (Augmentin)
d. cromolyn sodium (Intal)
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A 68-year-old man with a history of COPD is
admitted to the hospital for increasing
shortness of breath and a nonproductive
cough. Chest auscultation reveals expiratory
wheezes. Which of the following is the most
appropriate to improve the patient’s clinical
condition?
a. beclomethasone (Vanceril)
b. ipratropium bromide (Atrovent)
c. amoxicillin (Augmentin)
d. cromolyn sodium (Intal)

A patient is admitted to the hospital with
asthma triggered by a pulmonary infection.
The patient has coughed up mucus plugs. It is
most appropriate to administer:
a. a bronchodilator with strong alpha
stimulation
b. aerosolized ipratropium bromide (Atrovent)
c. mucolytic therapy followed by high
humidity
d. a bronchodliator followed by high humidity

A patient is admitted to the hospital with
asthma triggered by a pulmonary infection.
The patient has coughed up mucus plugs. It is
most appropriate to administer:
a. a bronchodilator with strong alpha
stimulation
b. aerosolized ipratropium bromide (Atrovent)
c. mucolytic therapy followed by high
humidity
d. a bronchodliator followed by high humidity

An MDI is ordered for a patient receiving
mechanical ventilation. Which of the following is
the most appropriate way to administer the
bronchodilator?
a. insert the MDI and spacer in the expiratory limb
of the ventilator
b. Place the MDI and spacer in the inspiratory
limb, close to the Y
c. increase the mandatory rate during the MDI
treatment
d. disconnect the ventilator circuit and discharge
the MDI directly into the endotracheal tube

An MDI is ordered for a patient receiving
mechanical ventilation. Which of the following is
the most appropriate way to administer the
bronchodilator?
a. insert the MDI and spacer in the expiratory limb
of the ventilator
b. Place the MDI and spacer in the inspiratory
limb, close to the Y
c. increase the mandatory rate during the MDI
treatment
d. disconnect the ventilator circuit and discharge
the MDI directly into the endotracheal tube

A patient with known reversible airway disease
administers two puffs from his MDI. After the
treatment an RT measures the patient’s peak flow
and notices that is has only increased marginally
from pre-administration. The therapist should:
a. add a spacer to the MDI
b. change the medication to a different beta-agonist
c. administer by a small-volume nebulizer
d. contact the attending physician of the peak flow
results

A patient with known reversible airway disease
administers two puffs from his MDI. After the
treatment an RT measures the patient’s peak flow
and notices that is has only increased marginally
from pre-administration. The therapist should:
a. add a spacer to the MDI
b. change the medication to a different beta-agonist
c. administer by a small-volume nebulizer
d. contact the attending physician of the peak flow
results