1. Allergy and Respiratory Medications
Chapter 11
Allergy and Respiratory Medications
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 1

2. Learning Objectives
Identify major antihistamines used to treat breathing problems
Describe the action of antitussive medications
List medications used to treat and prevent asthma attacks
Describe the major actions and the adverse reactions of the two main categories of bronchodilators
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

3. Types of AntiHistamines
ALKYLAMINES
bromopheniramine
(Dimetapp)
chlorpheniramine
(Chlo-Trimeton)
ETHANOLAMINES
diphenhydramine
(Benadryl)
PHENOTHIAZINE
promethazine
(Phenergan)
PIPERIDINES
cetirizine (Zyrtec)
fexofenadine (Allegra)
lorantidine (Claritin)
PIPERAZINE
hydroxyzine (Vistaril)
MISCELLANEOUS
azelastine (Astelin)
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

4. Antihistamines (cont.)
Uses
Seasonal allergic rhinitis (SAR)
Perennial allergic rhinitis (PAR)
Perennial nonallergic rhinitis (PNAR)
Relieve symptoms of allergic disorders
Adjunctive therapy for anaphylaxis
Sedation
Allergic rhinitis is a condition in which a person has a reaction to outdoor allergens (SAR) or indoor allergens (PAR). Perennial nonallergic rhinitis (PNAR) is a condition in which inflammatory symptoms are caused by problems other than allergens.
Histamine plays a role in producing the inflammatory symptoms in these conditions: watery eyes, nasal stuffiness, postnasal drip, and sneezing.
Antihistamines are used for hives, angioneurotic edema, serum sickness, and blood-product reactions and are a common ingredient in cold remedies because they decrease mucus secretion and cause drowsiness at bedtime.
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

5. Antihistamines Action
Compete with histamine for H1 receptor sites to limit its effectiveness
Limits vasodilation, capillary permeability, and swelling
Limits acetylcholine release, which dries secretions in the bronchioles and gastrointestinal system
Sedative effect on the CNS
Histamine is released (by mast cells and basophils) when the body is injured.
Histamine dilates the capillaries of the smooth muscle and vascular system.
Antihistamines relieve the effects of histamine on body organs and structures.
The six major groups of antihistamines are found in Table These groups vary in characteristics and action.
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

6. Antihistamines (cont.)
Adverse Reactions
Changes in blood pressure, blurred vision
Tachycardia, insomnia, dry mouth, nausea
Restlessness, excitability, sedation, tinnitus
Drug Interactions
Nursing Process
Some patients might experience CNS overstimulation and others CNS sedation from antihypertensives.
Antihistamine overdosage is potentially fatal, particularly in children, because the CNS is stimulated and depressed at the same time.
What drugs increase the effect of antihistamines? (CNS depressants such as hypnotics, sedatives, tranquilizers, depressant analgesics, alcohol)
Antihypertensives strengthen the action of other drugs such as anticholinergics and may mask ototoxicity from drug therapy. These medications also can interfere with the effect of anticholinesterase drugs and may decrease the effect of corticosteroids and hormones.
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

7. Antihistamines Life span considerations Pediatrics: Elderly
Infants and young children often have anticholinergic side/adverse effects
Paradoxical reactions may occur: increased nervousness, confusion, or hyperexcitability
Elderly
More likely to develop side effects such as dizziness, syncope (fainting), confusion, and extrapyramidal reactions
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

8. Question 1
Which of the following is NOT an adverse reaction that may develop from taking antihistamines?
Hypertension
Hypotension
Tachycardia
Bradycardia
Correct Answer: 4
Rationale: Some of the adverse reactions that may develop in the patient receiving antihistamines include hypertension (high blood pressure), hypotension (low blood pressure), tachycardia (rapid heartbeat), blurred vision, confusion, dizziness, drowsiness, excitation, insomnia (inability to sleep), paradoxical excitation (when a patient shows stimulation rather than the usual sedation), restlessness, sedation, tinnitus (ringing in the ears), anorexia (lack of appetite), constipation, diarrhea, dry mouth, nausea, vomiting, difficult or painful urination, impotence, urinary retention or frequency, photosensitivity (abnormal response to exposure to sunlight), rash, urticaria (itching), nasal congestion, and thickening of bronchial secretions because of direct mucosal drying.
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

9. Types of Antitussives Narcotic Non-Narcotic codeine phosphate
codeine sulfate
Non-Narcotic
dextromethorphan
Robitussin
Vick’s Formula 44
diphenhydramine
Benadryl
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

10. Antitussives Actions: Uses: Depress the cough center in the brain
Anesthetize stretch receptors in the respiratory tract
Soothe irritated areas in the throat
Uses:
Relief of overactive or nonproductive cough
Antitussives have central, peripheral, and local nervous system effects in the body.
Antitussives are commonly combined with other drugs and are usually sold as OTC drugs. Antitussives with codeine are typically sold as prescription drugs.
Antitussives with codeine depress the cough center in the brain. Antitussives without codeine act only peripherally and locally in the body.
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

11. Antitussives (cont.) Adverse Reactions Drug Interactions
Constipation, drowsiness, dry mouth, nausea, postural hypotension
Drug Interactions
Nursing Process
Antitussives have an additive effect with other CNS depressants and increase the analgesic effect of aspirin.
In reviewing the nursing process, what assessments should a nurse make before administering an antitussive with codeine? What nursing diagnoses could be made?
What planning should be done? Implementation? What should the nurse evaluate to verify medication effectiveness?
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

12. ASTHMA PREVENTION INTAL (cromolyn sodium)
Action: slows destruction of mast cell which releases the histamine resulting in decreased histamine circulation
ONLY for prophylaxis
NOT A RESCUE MEDICATION
Must be inhaled on a set schedule
Symptoms improve within 4 weeks
See MD at weeks 2 & 4
Do not stop drug abruptly

13. Types of Asthma Bronchodilators
Sympathomimetic
(Rescue Drugs)
Proventil / Ventolin
(albuterol***)
Adrenalin Chloride
(epinephrine)
Isuprel
(isoproterenol)
Alupent
(metaproterenol)
Serevent (salmeterol)
Brethine (terbutaline)
Xanthine (-phylline)
Aminophylline
Slo-Phyllin
(theophylline)
*** albuterol has less cardiac
side effects & longer bronchodilation
than remainder of drugs listed

14. Action of Bronchodilators
Open the airway by stimulating Beta 2 receptors
Some drugs have greater effects on Beta 1 (heart) than others
Sympathomimetic drugs mimic epinephrine stimulation as side effects
Tachycardia and insomnia are frequently seen.

15. Additional Asthma meds
Leukotriene receptor inhibitors (for chronic use); decreases the interleukine release from the injured tissues. NOT a rescue medication
Singulair
(montelukast)
Accolate
(zafirlukast)

16. Corticosteroid Use for Asthma/ COPD
Systemic
methylprednisolone
prednisolone
prednisone
Inhaled
Beclovent
(beclomethasone)
Pulmicort (cortisone for pulmonary tract)
(budesonide)
Aerobid (flunisolide)
Flovent (fluticasone propionate)
Azmacort (triamcinolone acetonide)

17. Intranasal Steroids (Sprays)
Beconase (beclomethasone dipropionate)
Rhinocort Aqua (Budesonide)
Aerobid (flunisolide)
Flonase (fluticasone propionate)
Nasonex (mometasone furoate)
Nasocort AQ (triamcinolone acetonide)
Many are the same as inhaler medications but reformulated for spray application
Effects are topical unless swallowed

18. Actions of Corticosteroid Usage
‘… the most potent and consistently effective medication for long term control of asthma.”
Anti-inflammatory; decrease reaction to allergens
Systemic steroids are used to get quick control of the airway then inhaled steroids will be used to maintain the effect.
Inhaled drugs have a local effect; better for long term use
RINSE the mouth after steroid inhalation to prevent thrush

19. Remember: COME -TAPE- FIGS
C = Cataracts
O = Osteoporosis
M = Mood changes
E = Elevated blood sugar
T = Thin skin
A = Addison’s disease
P = Peptic ulcers
E = Electrolyte imbalance
F = Fluid retention
I = Increased risk of infection
G = Gain Weight
S = Short stature (if taken as a child)

20. Decongestants
Affect alpha cells in blood vessels in nose tissue = vasoconstriction, decreased fluid movement and edema.
Prolonged use can lead to rebound vasodilation causing more congestion.
Used for congestion in nose, middle ear and Eustachian tube. Decreasing congestion around the auditory tube allows the middle ear to better drain
NOT to be used in infants and toddlers
Systemic decongestants work better than topical but also have more side effects than topical drugs.

21. Nasal Decongestants Sympathomimetic bronchodilators Inhalers
ephdrine
Epinephrine *
* denotes drug used by MDs on a daily basis
Inhalers
Afrin / Dristan
(oxymetazoline)
Neo-Synephrine
(phenylephrine)
Sudafed
(pseudoephedrine sulfate)

22. Expectorants
Decrease the thickness of the mucus (by increasing the water content) in the respiratory tract to aid in the ability to remove it. Increases ciliary movement so cough is effective.
Anti- tuss/ Robitussin/ Mucinex (guaifenesin) Used often; may increase bleeding tendency. Monitor for bruising or bleeding especially if taking anticoagulants
SSKI (iodine products) – use infrequently

23. Practice
A 29 year old male comes to the ED with c/o SOB, wheezing and chest pain when he coughs.
1. What assessments do you perform?
2. What lab tests should be ordered?
3. Would you start an IV (assume orders are present)? What kind? Why?
4. What medications would the nurse anticipate being ordered?
5. What patient teaching should be considered?

24. QUESTIONS?