Antihistamines and Nasal Decongestants

Respiratory Drugs

Common Cold
Virus infection
Rhinovirus Influenza virus
Initiates the inflammatory response

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Common Cold
Cough reflex
Irritant stimulates sensory receptors Removes
Respiratory secretions Foreign object

Respiratory Drugs

Inflammatory Response
Mucosal irritation Release of several inflammatory and vasoactive substances
Histamine Dilating small blood vessels in the nasal sinuses
Produces nasal congestion

Respiratory Drugs

Symptomatic Treatment
Combined use of:
Antihistamines, nasal decongestants, antitussives, and expectorants

Respiratory Drugs

Antihistamines and Nasal Decongestants

Compete with histamine for receptor sites Two histamine receptors
H1 (histamine 1) H2 (histamine 2)

Respiratory Drugs

VasodilatationGI effects
Increase gastrointestinal and respiratory secretions Increase capillary permeability The binding of H1 and H2 blockers to histamine receptors prevent histamine stimulation

Respiratory Drugs

H1 Antagonists
Respiratory antihistamines Effects
Antihistaminic Mild anticholinergic
Parasympathetic nervous system

Sedative

Respiratory Drugs

Antihistamines
Antihistamines
Cardiovascular: small blood vessels

Histamine effects
Dilation Permeability

Antihistamine effects
Prevent dilation Prevent increased permeability
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Antihistamines
Skin
Prevent itching Wheal and flare

Anticholinergic
Drying effect

Sedative
Drowsiness

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Antihistamines

Management of:
Nasal allergies Seasonal or perennial allergic rhinitis Allergic reactions Motion sickness

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Antihistamines

More effective in prevention Give early

Prevent binding of histamine receptors

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Classes of Antihistamines
Two types
Traditional: sedating Nonsedating

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Traditional Antihistamines
Older Work both peripherally and centrally Anticholinergic properties Examples: diphenhydramine (Benadryl) and chlorpheniramine (ChlorTrimeton)
Respiratory Drugs 14

Nonsedating/Peripherally Acting Antihistamines

Work peripherally
Eliminate sedation

Longer duration of action

Increases compliance

Examples: fexofenadine (Allegra) and loratadine (Claritin)

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Antihistamines: Nursing Implications

Assess allergy history Contraindicated
Asthma attacks Chronic obstructive pulmonary disease Cardiovascular disease

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Client Teaching
Instruction for traditional/sedating antihistamines
Avoid driving No alcohol No central nervous system depressants

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Nasal Decongestants
Two main types are used:
Adrenergics (largest group)
Constrict dilated blood vessels
Nasal mucosa

Corticosteroids
Reduce inflammation

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Goal of Nasal Decongestants

To reduce congestion Two dosage forms
Oral Topical
Nasal spray

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Oral Decongestants
Prolonged effects Less potent No rebound congestion Exclusively adrenergics Example: pseudoephedrine (Sudafed)

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Topical Decongestants
Adrenergics
Prompt onset Sustained userebound congestion

Both adrenergics and steroids

Potent; work well

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Nasal Steroids
Anti-inflammatory
Decrease inflammation Relieve nasal congestion

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Nasal Decongestants
Adrenergics
Ephedrine (Vicks) Naphazoline (Privine) Oxymetazoline (Afrin) Phenylephrine (Neosynephrine)

Intranasal steroids
Beclomethasone dipropionate
Beconase Vancenase

Flunisolide (Nasalide)

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Nasal Decongestants: Side Effects

Adrenergics
Nervousness Insomnia Palpitations Tremors

Steroids
Local mucosal dryness and irritation

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Treatment with Nasal Decongestants

Acute or chronic rhinitis Common cold Sinusitis Hay fever Other allergies

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Nasal Decongestants: Nursing Implications

Avoid decongestants in the following clients:
Heart disease
Hypertensive disease

Respiratory disease

Assess for drug allergies

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Expectorants and Antitussive Agents

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Expectorants and Antitussive Agents

Drugs that aid in the expectoration (removal) of mucus Reduce the viscosity of secretions Stimulate the flow of respiratory secretions

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Secretions
By loosening and thinning sputum and bronchial secretions, the tendency to cough is indirectly diminished.

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Cough Relief
Relief of nonproductive coughs:
Pertussis Common cold Bronchitis Laryngitis Sinusitis Influenza Pharyngitis
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Expectorants: Side Effects

Common side effects Guaifenesin
Nausea, vomiting Gastric irritation

Terpin hydrate
Gastric upset (elixir has high alcohol content)

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Expectorants: Nursing Implications

Use with caution.
Elderly

Encourage client to drink fluids. Monitor for therapeutic effects. Report a fever lasting longer than a week.

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Antitussives
Drugs used to control coughing
Opioids and nonopioids Narcotics
Used for nonproductive coughs

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Opioid Antitussives
Suppress the cough reflex by direct action on the cough center in the medulla
Example: codeine + guiafenesin = Robitussin AC

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Non-narcotic Antitussives
Dextromethorphan
Suppresses the cough reflex by direct action on the cough center in the medulla; a chemical derivative of the opiate narcotics

Result: diminished cough Produces no respiratory depression, analgesia, or dependence Example: Robitussin-DM
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Non-narcotic Antitussives

Benzonatate
A derivative of procaine (local anesthetic action); impairs the sensation of the stretch receptors in the respiratory tract Example
Tessalon

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Antitussive Agents: Side Effects

Benzonatate
Dizziness, headache, sedation

Dextromethorphan
Dizziness, drowsiness, nausea

Opioids
Sedation, nausea, vomiting, lightheadedness, constipation
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Antitussive Agents: Nursing Interventions

Perform respiratory assessment. Instruct clients to:
Avoid driving or operating heavy equipment Not drink liquids for 30 to 35 minutes after taking a cough syrup or using a cough lozenge

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Antitussive Agents: Client Teaching

Report any of the following symptoms to the health care professional:
Cough that lasts more than 2 weeks A persistent headache Fever Rash
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Bronchodilators and Other Respiratory Agents

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Bronchodilators
Medications used to relax and open the airways Open or maintain the bronchial airways Treat several disease syndromes
Chronic obstructive pulmonary disease Asthma
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Classes of Bronchodilators
Sympathomimetic agents Xanthine bronchodilators Anticholinergics Leukotriene receptor antagonists 5-lipoxygenase inhibitors Mast cell stabilizers Corticosteroids
Respiratory Drugs 42

Sympathomimetics
Beta2-adrenergic receptors
Used during the acute phase of asthmatic attacks Quickly reduce airway constriction and restore normal airflow

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Uses for Sympathomimetics

Treat acute attacks as well as prevent attacks Quickly reduce airway constriction and restore normal airflow Relief of bronchospasm, bronchial asthma, bronchitis, and other pulmonary diseases Treat hypotension and shock Produce uterine relaxation to prevent Respiratory Drugs 44 premature labor

Sympathomimetic Agents
Nonselective adrenergics
Stimulate alpha1, beta1 (cardiac), and beta2 (respiratory) receptors Example: epinephrine

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Sympathomimetic Agents

Nonselective beta-adrenergics
Stimulate both beta1 and beta2 receptors
Example: isoproterenol (Isuprel)

Selective beta2 drugs

Stimulate only beta2 receptors Example: albuterol

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Sympathomimetic Agents
Frequent use leads to beta1 receptors being stimulated
Albuterol loses its action

General side effects

Nausea, increased anxiety, palpitations, tremors, and increased heart rate

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Xanthines
Chemical class of agents
Contain caffeine

Oldest class of bronchodilators

Used in ancient times

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Xanthine Bronchodilators: Mechanism of Action

Increase levels of energy-producing cAMP Inhibit phosphodiesterase Result
Enzyme that breaks down cAMP
Smooth muscle relaxation Bronchodilation Increase airflow (oxygen/carbon dioxide) in the lungs Cause cardiac life-threatening side effects
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Xanthine Derivatives: Side Effects

Nausea, vomiting, anorexia Gastroesophageal reflux during sleep Sinus tachycardia, extrasystole, palpitations, ventricular dysrhythmias Transient increased urination

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Anticholinergics: Mechanism of Action

Acetylcholine (ACh) causes bronchial constriction. Anticholinergics bind to the ACh receptors, preventing ACh from binding. Result: bronchoconstriction is prevented, airways dilate

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Anticholinergic Bronchodilators
Ipratropium bromide (Atrovent) Tiotropium bromide (Spiriva HandiHaler) Actions
Local effects Slow and prolonged action Used to prevent bronchoconstriction Not used for acute asthma exacerbations!

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Anticholinergics: Side Effects

Usually not absorbed systemically If absorbed, have the potential to produce:
Dry mouth or dry throat Gastrointestinal distress Headache Coughing Anxiety
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Leukotriene Receptor Antagonists

Directly prevent bronchoconstriction Developed to treat asthma Popular and effective Leukotrienes are inflammatory molecules
Released by mast cells Cause the bronchials to contract Development of edema in the lungs
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Leukotriene Receptor Antagonists

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
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Leukotriene Receptor Antagonists

Currently available agents:
Montelukast (Singulair) Zafirlukast (Accolate)

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Leukotriene Receptor Antagonists: Side Effects

Headache Nausea Diarrhea Liver dysfunction

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Leukotriene Receptor Antagonists: Client Education

Educate the client.
Use for chronic management of asthma, not acute asthma Improvement should be seen in about 1 week

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5-Lipoxygenase Inhibitors
New class of leukotriene receptor antagonists Action
Inhibit the formation of leukotrienes Used to inhibit some cancer growth

Outcome
Prevent lung inflammation

Example
One agent: Zileuton Respiratory Drugs
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Mast Cell Stabilizers

Used prophylactically No direct bronchodilator activity Indirect-acting Stabilize the cell membranes of the inflammatory cellsmast cells, monocytes, macrophages
Prevent release of harmful cellular contents
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Mast Cell Stabilizers

Adjuncts to the overall management of clients with lung disease Prevent bronchospasm when exposed to:
Cold air Exercise Allergens Dry air
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Mast Cell Stabilizers: Examples

Cromolyn (Nasalcrom, Intal) Nedocromil (Tilade)

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Mast Cell Stabilizers: Side Effects

Coughing Taste changes Sore throat Dizziness Rhinitis Headache Bronchospasm
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Inhaled Corticosteroids
Anti-inflammatory Inhaled forms
Reduce systemic effects Used for chronic asthma

Does not relieve acute asthma

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Inhaled Corticosteroids

Stabilize membranes of cells that release harmful bronchoconstricting substances Also increase responsiveness of bronchial smooth muscle to beta-adrenergic stimulation

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Inhaled Corticosteroids: Examples

Beclomethasone dipropionate (Beclovent, Vanceril) Triamcinolone acetonide (Azmacort) Flunisolide (AeroBid)

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Inhaled Corticosteroids: Side Effects

Pharyngeal irritation Coughing Dry mouth Oral fungal infections Systemic effects are rare

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Respiratory Agents
Combination product
Fluticasone propionate and salmeterol (Advair): a dry powder in a circular diskus Salmeterol: long-acting bronchodilator Corticosteroid: anti-inflammatory agent
Used daily

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Respiratory Agents: Client Education

Instruct clients to:
Receive flu and pneumonia vaccination Receive prompt treatment for any illness Check with health care provider before taking other medications

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