Transcript Respiratory Update for SCC Nursing Faculty

Respiratory Update for SCC
Nursing Faculty
Respiratory Medications – Refresher and
Update on Recent Changes
Presented by Cynthia Fouts
June, 2012
Learning Objectives:
At the conclusion of viewing this presentation, the learner will be able to

classify respiratory medications.

explain the reason for MDI changes which have occurred over the past
decade.

demonstrate the procedure for administration of both MDI and DPI
medications.

list recently discontinued respiratory medications
As of June, 2012, there are 93 FDA approved
drugs for use to treat respiratory ailments.
This presentation will cover 12 medications
which have been approved in the last
decade. It will also discuss new delivery
methods for previously approved
medications and medications used in
different therapeutic applications.
Respiratory Medication Classifications

Antihistamines

Antitussives

Bronchodilators
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Inhaled Corticosteroids
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Decongestants
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Mucolytics
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Non-steroidal antiasthma agents
There are other respiratory medications but
most fall within these categories.
Antihistamines

block histamine; decrease inflammation and reduce
secretions

2nd generation – cause less drowsiness than the 1st
generation antihistamines

also have anti-cholinergic effect – cause dry mouth
Antitussives


suppress the cough reflex at the medulla oblongata;
narcotics may depress respiratory drive

benzonatate – narcotic

butamirate citrate – non-narcotic

codeine – narcotic

dextromethorphan – non-narcotic

hydrocodone – narcotic
important - ensure the patient don’t suffer from
pooling of secretions if cough is suppressed.
Bronchodilators

dilate the airways by releasing constriction of the
muscles surrounding them

3 different classifications

Xanthines

Sympathomimetics (Adrenergic)

Parasympatholytic (Anticholinergics)
Bronchodilator - Xanthines
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stimulate the CNS thus stimulating respiration,
dilating coronary and pulmonary arteries, and act
as a diuretic.

Theophylline, Aminophylline, Caffeine

2nd or 3rd line agent in treating COPD and asthma

useful in treating Apnea of Prematurity
Bronchodilator - Sympathomimetics

mimic the effect of the sympathetic nervous
system to dilate the bronchi and increase the rate
and depth of respiration

most are beta2 specific – increase concentration of
cellular cAMP

short-acting and long-acting beta agonists (SABA,
LABA)

albuterol, bitolterol, salbutamol, terbutaline,
racemic ephiniphrine, levalbuterol
Bronchodilator - Anticholinergics

blocks effects of acetylcholine at the cholinergic
receptors on bronchial smooth muscle

Ipratroprium bromide and tiotropium bromide

specifically approved for COPD but may be used in
treatment of asthma also.

studies have shown additive effect when used in
conjunction with beta agonists.
Inhaled Corticosteroids

decrease inflammatory response within the airways

when inhaled, systemic side effects are diminished

long-term use in treatment of COPD and Asthma

always rinse the mouth after inhalation of a steroid
to reduce incidence of oral thrush

Flunisolide, fluticasone, budesonide, mometasone,
ciclesonide
NOT FOR EMERGENCY USE – DO NOT USE
DURING AN ACUTE ASTHMA ATTACK.
Decongestants

decrease blood flow to upper respiratory tract and
decrease excessive production of secretions

especially useful in allergic rhinitis

may be given orally or by nasal spray
Mucolytics

Acetylcysteine – decreases the viscosity of sputum
by breaking the disulfide bonds which connect the
mucin proteins.

Not shown to really be helpful in treating lung
diseases

may be given orally as an antioxidant antidote to
reduce liver injury with acetaminophen overdose
Mucolytics
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Dornase alpha – a peptide mucolytic which reduces
extracellular DNA and F0actin polymers

indicated in treatment of cystic fibrosis

currently being used in treatment of other
pulmonary diseases although no efficacy has yet
been shown
Non-steroidal Anti-asthma Agents
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anti-inflammatory effect through mechanism
different from corticosteroids
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stop the inflammatory process

mast cell stabilizer – cromolyn sodium
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antileukotrienes – accolate, singuair, zyflor
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monoclonal antibodies - xolair
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prophylactic management (control) of mild
persistent asthma
Why are MDI’s being changed?
The Montreal Protocol is an international treaty intended to
eliminate the use of substances that contribute to destroying
the ozone layer, including CFCs (chlorofluocarbons).
The most commonly used inhalers were changed over to
the new HFA propellant or remade as dry powder inhalers
(DPI).
In switching to the new HFA format, it was discovered that
dose delivery is actually enhanced with delivery by HFA as
opposed to CFC – a win-win situation!
Comparison of dose delivery between CFC inhalers,
HFA inhalers, and DPIs.
The following is a list of inhalers to be discontinued
along with the corresponding date
nedocromil , June 14, 2010
metaproterenol , June 14, 2010
triamcinolone , December 31, 2010
cromolyn , December 31, 2010 (available as nebulized solution)
flunisolide , June 30, 2011
combivent, December 31, 2013 (replaced with Combivent Respimat)
pirbuterol , December 31, 2013
Now for a look at the new respiratory
medications introduced within the past
decade.
Alvesco (ciclesonide)
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Approved January, 2008
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Prophylactic maintenance treatment of asthma
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Prodrug delivered via metered dose inhaler (MDI)

12 time greater affinity for glucocorticoid receptors than
dexamethasone.

80 mcg or 160 mcg
Arcapta (indacaterol maleate inhalation powder
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approved July, 2011
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long-acting beta2-adrenergic agonist (LABA)
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once daily inhalation of one 75 mg. capsule
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correct administration - dry powder inhaler
taken via the neohaler using the same
technique as the spiriva handihaler.
Brovana (arformoterol tartrate)
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approved October, 2006
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selective beta2-adrenergic bronchodilator

long-term twice-daily maintenance therapy for COPD
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156 mcg administered twice a day by nebulizer
Daliresp (roflumilast)
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approved February, 2011
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selective phosphodiesterate 4 (PDE4) inhibitor
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reduces release of inflammation mediators
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useful in treatment of COPD
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500 mcg tablet taken orally daily, with or without food
Dulera (mometasone furoate + formoterol fumarate
dihydrate)
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approved June, 2010
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for treatment of asthma
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combination therapy of corticosteroid plus LABA
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Dosage dependent on previous therapy
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100 mcg/5 mcg up to 800 mcg/20 mcg BID by
inhalation from MDI
Dymista (azelastine hydrochloride
and fluticasone proprionate)

approved May, 2012

treatment for seasonal allergic rhinitis

combination therapy of antihistamine
and corticosteroid
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sprayed suspension for intranasal
administration
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one spray per nostril twice daily

prime spray prior to initial use and if not
used for 14 days.
Patanase (olopatadine hydrochloride)

approved April, 2008
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treatment of seasonal allergic rhinitis
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antihistamine
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metered-dose manual spray pump for
intranasal administration
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two sprays per nostril twice daily
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prime prior to initial use and if not
used for more than 7 days
Pulmozyme (dornase alfa)
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approved March, 1998
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mucolytic
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Although this drug was approved prior to 10 years ago, it has
seen an increase in usage lately as a mucolytic for COPD
patients.

Efficacy has not been shown in any trials for COPD therapy
Qnasl (beclomethasone dipropionate)
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approved March, 2012
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treatment of seasonal and perennial allergic rhinitis
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anti-inflammatory steroid
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non-aqueous nasal spray solution for intranasal
inhalation
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80 mcg/spray administered as two sprays in each
nostril once daily (total of 320 mcg/day)
Spiriva (tiotropium bromide)

approved February, 2004

treatment of bronchospasm associated
with COPD

anticholinergic

18 mcg supplied in a gelatin capsule
administered via the HandiHaler; one
capsule daily
http://www.youtube.com/watch?v=bXHHFmZ
_DRI&feature=related
Spiriva (tiotropium bromide)

2.5 mcg supplied in the Respimat inhaler; 2
puffs daily

used with caution in patients with known
cardiac rhythm disorders
http://www.youtube.com/watch?v=cIYKXuIWG
fA&feature=related
Xolair (omalizumab)

approved June, 2003
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treatment of moderate to severe persistent asthma
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binds to human immunoglobulin E (IgE) which is responsible
for release of mediators of the allergic response
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powder for reconstitution into solution for
subcutaneous injection
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150 to 375 mg SC every 2 or 4 wks
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dose and frequency determined by serum
total IgE level.
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limit injection site to not more than 150 mg.
Zemaira (alpha-1-proteinase inhibitor)
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approved July 2003

treatment of alpha-1-proteinase inhibitor (A1-PI) deficiency
emphysema

intravenous therapy

chronic augmentation and maintenance of A1-PI deficiency and
clinical evidence of emphysema
Some old favorites take on a
different look!
Combivent Respimat
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approved March, 2012

Combination of Albuterol
and Ipratropium Bromide
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Slow-moving mist
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Propellant-free delivery
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Only one inhalation per dose
as opposed to the old MDI
which requires 2 puffs per
dose
The Advair diskus is approved for treatment of both
COPD and Asthma. The HFA inhaler, approved in July,
2008, is only for the treatment of Asthma.
http://www.youtube.com/watch?v=_iEEVkMU1IA
Serevent is approved for the treatment of both
COPD and Asthma. It is NOT designed to be a
rescue inhaler used to treat an acute asthma
attack.
HFA inhaler approved June, 2006.
Bibliography

Boehringer Ingelheim receives FDA approval for COMBIVENT RESPIMAT to treat
COPD. (2011). Medical News. Retrieved from: http://newsmedical.net/news/20111010/Boehringer-Ingelheim-rece-ves-FDA-apaproval-forCOMBIVENT-RESPIMAT-to-treat-COPD.aspx

Gardenhire, D. (2012). Rau’s Respiratory Care Pharmacology, 8th Ed., St. Louis:
Elsevier Mosby .

Pinoy nurze. (2008). Drugs Affecting the Respiratory System. Retrieved from:
http://www.slideshare.net/pinoynurze2/pharmacology-respiratory-drugs-380509

Reinventing Metered Dose Inhalers: From Poorly Efficient CFC MDIs to Highly
Efficient HFA MDIs. (2003). Drug Development and Delivery (31). Retrieved from
http://www.drugdeliverytech.com/ME2/dirmod.asp?sid=&nm=&type=Publishing&
mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791&ti
er=4&id=53E82363413A44F6AD01FDFF8D242DFE
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Respiratory Drugs (2012) MediLexicon. Retrieved from:
http://medilexicon.com/drugs-list/respiratory.php