RESCUE or
MAINTENANCE?
MAINTENANCE?
Which of the following meds you learned this week is to be used as an emergency (rescue) med for a patient with asthma?
(a) albuterol (Proventil)
(b) beclomethasone (Qvar)
(c) montelukast (Singulair)
(d) theophylline (Theo)
A. ALBUTEROL (Proventil)
The above is a Short-Acting Beta2- Agonist (SABA).
All the rest are different types of long-acting drugs for the longer-term "maintenance" treatment of asthma, NOT to be used for acute exacerbations or emergencies.
Your patient has been prescribed BOTH an anti-inflammatory and a bronchodilator for the treatment of their asthma. WHICH of the two should you give to them first, and why?
BRONCHODILATOR first
Because you want to OPEN UP the airways of the lungs first, allowing for greater success in the delivery of the anti-inflammatory drug that you administer second.
This is the name of the common 1st Generation antihistamine that is commonly bought Over The Counter (OTC).
Bonus points: When not OTC, what other ways can this drug be given (i.e. other methods of delivery), aside from PO?
diphenhydramine (BENADRYL)
BONUS: Also available PRN in both IV and intramuscular (IM) injection forms
in a healthcare setting
This drug, which sometimes is used in emergency situations to lower someone's Potassium level, also has the potential AE of causing a patient to experience TOO LOW of a Potassium level (hypokalemia)
Note that the LABA we were introduced, salmeterol (Serevent) can also cause hypokalemia over time, but it would not be used in an emergency situation.
Select the type of inhaler that does NOT require a lot of "breath-hand" coordination, it ONLY requires that a patient is able to take in a deep breath:
(a) Metered Dose Inhaler (MDI)
OR
(b) Dry Powder Inhaler (DPI)
(b) Dry Powder Inhaler (DPI)
[Note: in contrast, MDIs DO require a significant amount of "breath-hand" coordination]
You have heard that some ambulances have a constantly running nebulizer containing the SABA drug that we learned about this week. What's the name of that drug again, and would that drug in its nebulizer form be considered for use in "rescue" or "maintenance" situations?
albuterol (Proventil) -- RESCUE
Regardless of the method of delivery, this SABA is a rescue drug. In this scenario, it's regular use on an ambulance is also a big hint. The nebulizer is good for use with children, geriatrics, or other patients for whom its important to deliver a larger amount of the drug into the lungs faster than possible with MDIs.
Are Beta-2 Receptor Agonists, such as albuterol (Proventil/Ventolin) and salmeterol (Serevent), considered bronchodilators or anti-inflammatory drugs?
BRONCHODILATORS
[Their Method of Action (MOA): their selective activation of Beta2 receptors in the lungs causes bronchodilation]
Which generation antihistamine is cetirizine (Zyrtec): 1st, 2nd, or 3rd?
SECOND GENERATION
DRY MOUTH
(recall that Anticholinergics commonly dry out mucus membranes)
Select the one specific delivery device for respiratory meds that patients should always use together with a SPACER:
(a) Dry Powder Inhaler (DPI)
(b) Nebulizer
(c) Metered Dose Inhaler (MDI)
(d) Respimat
(Bonus points: WHY use a spacer with this device?)
(c) Metered Dose Inhaler (MDI)
[Bonus: because it allows a much higher percentage of the inhaled drug to reach all the way into the lungs where it is effective, from 5-9% without a spacer up to 21-25% with a spacer, more than double!]
What is the name of the Long-Acting Beta2 Agonist (LABA) for the treatment of asthma that we learned about in the unit this week, and would that be considered "rescue" or "maintenance"?
[Note: Anything "long-acting" will automatically fall into the "maintenance" rather than "rescue" category]
Are inhaled corticosteroids such as beclomethasone (Qvar) considered bronchodilators or anti-inflammatory drugs?
ANTI-INFLAMMATORY
[Its Method of Action (MOA): suppresses inflammation by inhibiting migration and function of neutrophils and eosinophils, two types of WBCs which serve as inflammatory mediators among their other functions]
What is the major difference between the first generation antihistamine drug and those developed later (second and third generations)?
First generation commonly has a SEDATING effect (except those who have a "paradoxical" reaction);
The second and third generation antihistimaines do NOT produce a sedating effect
Name the Methylxanthine-class drug introduced this week as one of the respiratory drugs that is now only RARELY used for the treatment of asthma due to its many potential Adverse Effects and its very narrow therapeutic range (meaning that there is a major risk for toxicity if the drug levels are not monitored closely)
theophylline (Theo)
Name the nasal decongestant that has a high abuse potential since, when sold in its original active form, causes the release of norepinephrine (and thus contains the active ingredient that can be distilled to produce the stimulant known as meth amphetamine).
pseudoephedrine (Sudafed)
[So part of the patient teaching for this drug: Do not use together with meth amphetamine or cocaine, not to mention digoxin, anesthesia, or the type of antidepressants known as MAO inhibitors...]
Outside of a hospital or emergency-care setting, if a patient carried around a "rescue inhaler" for self-treatment of acute asthma exacerbations, which of the following are they most likely to be carrying:
(a) Respimat
(b) DPI
(c) MDI
(d) Nebulizer
(C) MDI (Metered Dose Inhaler)
Note: The MDI is the most common way that a patient carries around a SABA for rescue med delivery. Nebulizers are not generally portable, they are typically plugged in. Respimat and DPI, while portable, are different ways that other longer-term "maintenance" respiratory drugs are delivered.
Among the following four drugs, which two are anti-inflammatory drugs and which two are bronchodilators?
(a) ipratropium (Atrovent), an anticholinergic
(b) omalizumab (Xolair), anti-IgE monoclonal antibody
(c) montelukast (Singulair), a leukotriene modifier
(d) theophylline (Theo), a methylxanthine
Anti-Inflammatory: B & C
(b) omalizumab (Xolair), anti-IgE monoclonal antibody
(c) montelukast (Singulair), a leukotriene mo
difier
Bronchodilators: A & D
(a) ipratropium (Atrovent), an anticholinergic
(d) theophylline (Theo), a methylxanthine
Why might diphenhydramine (Benadryl), which crosses the Blood Brain Barrier, be one of the drugs listed on the Beers Criteria of drugs to only be used with CAUTION in geriatric patients?
Because in the elderly, its CNS adverse effects that cause altered mental status such as confusion, sedation, poor coordination, etc. tend to be even more pronounced, such that this drug could be very dangerous for them
There were TWO drugs introduced this week for the treatment of asthma that both can cause dry mouth as an Adverse Effect (AE), and therefore the Patient Teaching for both includes "rinse your mouth out after use" and "consider using sugar-free hard candy" to counter this AE.
Name BOTH these drugs
ipratropium (Atrovent)
AND
beclomethasone (Qvar)
Is guaifenesin (Mucinex) an expectorant or a mucolytic, and what is its Method of Action (MOA) to cause that effect?
EXPECTORANT
It reduces the viscosity of respiratory secretions, thus stimulating the production and expulsion of respiratory tract secretions (in other words, it helps to move mucus in the lungs OUT of the lungs when the patient "expectorates" -- coughs or spits it out as phlegm)
You heard of a patient on your unit in the hospital getting acetylcysteine (NAC), a mucolytic respiratory drug that is used to liquify mucus in the lungs, via nebulizer. Is that likely to be for use in this situation as a RESCUE or MAINTENANCE delivery of this drug to the patient?
RESCUE
In this form, the drug has a 1 min onset, and might be used in an emergency situation when the mucus build-up in the lungs is reaching a dangerous level of acuity, e.g. in advanced progression of pneumonia in a patient with COPD
Would you classify Symbicort (the brand name of a "combo" drug that Christine introduced for "overview only") as a bronchodilator or an anti-inflammatory drug?
YES.
This is a trick question, since it is a type of combination drug that contains both.
Symbicort contains formoterol, a LABA (notice that its generic name ends in "-terol," just like albuterol (a SABA) and salmetrol (a LABA) which are in the same class as formoterol) that bronchodilates;
AND it contains budesonide, a corticosteroid that like beclomethasone serves as an anti-inflammatory. The combination makes both more effective
Name the antihistamine drug that we learned this week that includes the Nursing Consideration/ Patient Teaching that it is NOT to be taken with fruit juice (especially not apple or orange or pineapple). Why is that?
fexofenadine (Allegra), 3rd gen antihistamine
Because taking fexofenadine together with fruit juice significantly decreases absorption of the drug
Name at least three common Adverse Effects experienced when taking the anti-tussin dextromethorphan (Delsym)
Nausea, Diarrhea, Rash, and significant Altered States of Consciousness (including hallucinations, euphoria, and dissociation)
Name the respiratory med used to treat asthma introduced this week that contains the Black Box Warning (BBW) that it may cause mood changes, anxiousness, depression, and even suicidal ideation, so patients given this drug should be asked about whether or not they have had thoughts of harming themselves
montelukast (SINGULAIR)