1. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Introduction to Clinical Pharmacology Chapter 31- Upper Respiratory Drugs

2. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Antihistamine: Actions Antihistamines blocks most, but not all the effects of histamine First-generation antihistamines bind nonselectively to central and peripheral H1 receptors and may result in CNS stimulation or depression Other first-generation drugs may have additional effects- antipruritic (anti-itching) or antiemetic (anti-nausea) effects Second-generation antihistamines are selective for peripheral H1 receptors and, as a group are less sedating

3. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Antihistamine: Uses The general uses of the antihistamines include: –Relief of the symptoms of seasonal and perennial allergies; allergic and vasomotor rhinitis; allergic conjunctivitis; mild and uncomplicated angioneurotic edema and urticaria; relief of allergic reactions to drugs, blood, or plasma; relief of coughs caused by colds or allergy; adjunctive therapy in anaphylactic shock; treatment of parkinsonism; relief of nausea and vomiting; relief of motion sickness; sedation; adjuncts to analgesics

4. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Antihistamine: Adverse Reactions Central nervous system reactions – –Drowsiness or sedation; disturbed coordination-loratadine/claritin-does not cause drowsiness Anticholinergic effects (cholinergic blocking)- –Dryness of mouth, nose, and throat; thickening of bronchial secretion

5. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Antihistamine: Contraindications and Precautions Contraindicated: During pregnancy and lactation –First-generation antihistamine: Patients with known hypersensitivity to the drugs, newborns, premature infants, nursing mothers, individuals undergoing monamine oxidase therapy and in patients with angle-closure glaugoma, stenosing peptic ulcer, symptomatic prostatic hypertrophy, and bladder neck obstruction

6. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Antihistamine: Contraindications and Precautions (cont’d) –Second-generation antihistamines: patients with known hypersensitivity –Cetirizine is contraindicated in patients who are hypersensitive to hydroxyzine Used with caution in patient with: bronchial asthma, cardiovascular disease, narrow-angle glaucoma, symptomatic prostatic hypertrophy, hypertension, impaired kidney function, peptic ulcer, urinary retention, pyloroduodenal obstruction, and hyperthyroidism

7. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Decongestants: Actions and Uses Actions: –Nasal decongestants: Sympathomimetic drugs, which produce localized vasoconstriction of the small blood vessels of the nasal membranes- reduces swelling of the nasal passages Uses: –Used to treat the congestion associated with the following conditions: Common cold; hay fever; sinusitis; allergic rhinitis; congestion associated with rhinitis

8. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Decongestants: Adverse Reactions and Contraindications Use of oral decongestants may result in the following adverse reactions: –Tachycardia and other cardiac arrhythmias; nervousness; restlessness; insomnia; blurred vision; nausea; vomiting Contraindicated: –patients with known hypersensitivity and patients taking monoamine oxidase inhibitors –Sustained-released pseudoephedrine is contraindicated in children below 12 years of age

9. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Decongestants: Precautions Decongestants are used cautiously in patients with: –Thyroid disease; diabetes mellitus; cardiovascular disease; prostatic hypertrophy; coronary artery disease; peripheral vascular disease; hypertension; glaucoma –Pregnant women should consult with their primary health care provider before using these drugs

10. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Decongestants: Interactions Interactant drugEffect of interaction MAOIsSevere headache, hypertension and possibly hypertensive crisis Beta-adrenergic blocking drugs Initial hypertension episode followed by bradycardia

11. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Antitussives, expectorants and mucolytics:Actions and Uses Some antitussives depress cough center located in medulla and are called centrally acting drugs Some antitussives are peripherally acting drugs, which act by anesthetizing stretch receptors in the respiratory passages, thereby decreasing coughing Antitussives are used to relieve nonproductive cough

12. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Mucolytics and Expectorants: Actions Drug with mucolytic activity appears to reduce viscosity of respiratory secretions by direct action on mucus Expectorants increase production of respiratory secretions, which in turn appears to decrease viscosity of mucus, helps to raise secretions from respiratory passage

13. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Antitussives, expectorants and mucolytics : Adverse Reactions Central nervous system reactions: –Sedation; dizziness; lightheadedness Gastrointestinal reactions: –Nausea; vomiting; constipation Nonprescription cough medicines containing two or more ingredients produce few adverse reactions when used as directed

14. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Antitussives, expectorants and mucolytics : Contraindications and Precautions Contraindicated in patients with known hypersensitivity to drugs Opioid antitussives are contraindicated in premature infants or during labor when delivery of premature infant is anticipated Expectorant potassium iodide is contraindicated during pregnancy-D

15. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Antitussives, expectorants and mucolytics : Contraindications and Precautions Used with caution in patients: –With persistent or chronic cough; cough accompanied by excessive secretions; high fever; rash; persistent headache or nausea or vomiting Expectorants are used cautiously during pregnancy and lactation and in patients with: –Persistent cough; severe respiratory insufficiency or asthma; older adults or debilitated patients

16. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Antitussives, expectorants and mucolytics : Contraindications and Precautions (cont’d) Antitussives containing codeine are used with caution during pregnancy and labor and in patients with COPD; acute asthmatic attack; preexisting respiratory disorders; acute abdominal conditions Opioid antitussives are used cautiously in patients with head injury and increased intracranial pressure; acute abdominal disorders; convulsive disorders; hepatic or renal impairment; prostatic hypertrophy; asthma or other respiratory conditions

17. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Antitussives, expectorants and mucolytics : Interactions Central nervous system (CNS) depressants and alcohol may cause additive depressant effects when administered with antitussives containing codeine When dextromethorphan is administered with monoamine oxidase inhibitors, patients may experience hypotension, fever, nausea, jerking motions to the leg, coma

18. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Antitussives, Mucolytics and Expectorants: Interactions (cont) Patient may experience hypokalemia; cardiac arrhythmias; or cardiac arrest when potassium-containing medications and potassium-sparing diuretics are administered with iodine products Thyroid function tests may also be altered by iodine

19. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Herbal Alert Eucalyptus –Used as a decongestant and expectorant-found as a component in OTC products for tx of sinusitis and pharyngitis Should not be used during pregnancy and lactation, children younger than 2 years of age

20. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Assessment Preadministration assessment: –Document type of cough and describe color and amount of any sputum present during preadministration assessment –Record vital signs as some patients with productive cough may have an infection

21. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Assessment Ongoing assessment: –Observe for therapeutic effect –Auscultate lung sounds, takes vital signs periodically –Describe and record in chart type of cough and frequency of coughing –Record whether cough interrupts sleep or causes pain in chest or other parts of body

22. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Ongoing Assessment If a cough is present, describe in your documentation the type of cough (productive or nonproductive) and the frequency

23. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Planning Expected outcome includes: –Optimal response to therapy –Support of patient needs related to managing adverse drug reactions –Understanding of and compliance with prescribed treatment regimen

24. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Implementation Promoting an optimal response to therapy: –Administer antitussives orally –Depression of cough reflex can cause secretions to pool in lungs –Indiscriminate use of antitussives by general public may prevent early diagnosis and treatment of serious disorders, such as lung cancer and emphysema

25. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Implementation Promoting an optimal response to therapy: Teaching –Fexofenadine: Not administered 2 hours after antacids Immediately before and after tx with acetylcysteine, Auscultate lungs and record findings of both assessments on client’s chart *If inserted into trach, keep suction available!

26. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Implementation Monitoring and managing patient’s needs: –Impaired oral mucous membrane: Dryness of the mouth, nose, and throat- offer the patient frequent sips of water or ice chips to relieve the symptom –Risk of injury: Assist the patient with ambulation Place the call light within easy reach and instruct to call before attempting to get out of bed and ambulating GERIATRICs- older adults are likely to experience injury from dizziness due to sensorimotor deficits such as hearing loss, visual impairments, or unsteady gait

27. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Implementation Educating the patient and family: –Advise patient to read label carefully, follow dosage recommendations, and consult primary health care provider if cough persists for more than 10 days or if fever or chest pain occurs –If taking oral capsules, do not chew or break open the capsules, swallow them whole –Do not use with alcohol or other CNS depressants-antidepressants, hypnotics, sedatives, tranquilizers

28. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Implement: educate –Nasal burning and stinging may occur with the topical decongestants-effect disappears after use –If using a spray decongestant, do not allow the tip of the container to touch the nasal mucosa and do not share the container with anyone

29. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Implementation Ineffective Airway Clearance –Take deep breaths –Instruct on diaphragmatic breathing

30. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Implementation- Educating the patient and family: –Nurse reviews the dosage regimen and possible adverse drug reactions with the patient –Antihistamines may cause dryness of the mouth and throat-provide frequent sips of water, suck on hard candy, chew gum –If gastric upset occurs, take this drug with food or meals

31. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Eval No evidence of injury Patient has a clear airway Mucous membranes are dry and intact