1
Q
Mucolytics function
- which drugs are mucolytics
- how are they administered
- what ADR can they cause?
A
1) drugs that react directly with mucus to make it less VISCOUS - makes coughing more productive
2) two agents:
- acetylcysteine
- hypertonic saline
both agents are administered via inhalation and unfortunately can trigger FURTHER BRONCHOSPASM
2
Q
Acetylcysteine indications
A
mucolytic, acetaminophen OD
3
Q
Acetylcysteine MOA
A
lowers mucus viscosity allowing for more productive cough
4
Q
acetylcysteine routes CAUTION
A
- nebulized inhalation
- oral tabs, IV (Acetaminophen OD)
5
Q
acetylcysteine adr
A
bronchospasm
6
Q
hypertonic saline indications
A
mucolytic
7
Q
MOA of hypertonic saline
A
restores moisture to pulmonary system and allows for more productive cough
8
Q
Route hypertonic saline
A
Nebulized inhalation preferred
9
Q
ADR hypertonic saline
A
bronchospasm
10
Q
Cough suppressants
- what does coughing involve?
- how is coughing initiated?
- what is cough beneficial for?
- when should a cough be suppressed?
A
- coughing is a complex reflex involving the CNS, PNS, and muscles of respiration
- can be initiated by the irritation of the bronchial mucosa or stimuli at sites distant froom the RT
- cough is often beneficial when removing foreign matter and excessive secretions- these should not be typically suppressed
- non-productive coughs that create discomfort or deprive a patient of sleep are reasonoable to suppress
11
Q
Antitussive drugs
A
- suppress cough but do NOT treat the underlying condition
- opioid antitussives-
- codeine
- non- opioid antitussives
- benzonotate
- antihistamines ( prromethazine, diphenhydramine)
- dextromethorphan
12
Q
codeine indcations
A
cough (off label)
pain managment
13
Q
US box warnings for codeine
A
- ultra rapid metabolism of codeine- life threatening respiratory depression has occurred. most cases after TONSILLECTOMY and or adenoidectomy. many had evidence of being ultra rapid metabolizer d/t CYP2D6 polymorphism
- cytochrome p450 3a4 inhibitors- coadministration may cause increased hydrocodone plasma
14
Q
MOA of Codeine
A
cough suppressant by direct central action in the medulla
- converted by CYP 2d6 into morphine
15
Q
contraindications for codeine
A
- pediatrics <12 y/o
- post op pain management in peds <18 who have undergone tonsillectomy or adenoiodectomy
- concurrent MAOI administration or within the last 14 days
16
Q
dextromethorphan indications
A
cough suppressant
17
Q
MOA dextromethorphan
A
depresses the medullary cough center and interrupts cough impulse transmission (similar structure to codeine)
18
Q
contraindications to dextromethorphan
A
concurrent administration with or w/in 2 weeks of an MAOI
19
Q
ADR of dextromethorphan
A
- euphoria - similar to ecstasy/ alcohol intoxication and at higher doses - ketamine - intense hallucinations
- drowsiness, dizziness, restlessness
20
Q
Benzonatate indications
A
cough suppressant
21
Q
Benzonatate MOA
A
topical anesthetic action suppresses cough by action on the respiratory stretch receptors
22
Q
ADRs of benzonatate
A
- sedation/ dizziness
- constipation
- OD: seizures, arrhythmias, death (especially in small children)
- bronchospasm if capsules are opened
23
Q
Antihistamines - diphenhydramine, promethazine, dooxylamine
indications
A
cough suppressant, many others
24
Q
MOA of Antihistamines - diphenhydramine, promethazine, dooxylamine
A
histamine 1 antagonist- located in respiratory tract and in brain- unsure of the exact mechanism
25
ADR of Antihistamines - diphenhydramine, promethazine, dooxylamine
1. anticholinergic effects- dry mouth, urinary retention
1. drowsiness, sedation
26
expectorants
drugs that render COUGHING MORE PRODUCTIVE by stimulating the flow of the respiratory tract secretions
* one agent- guafenesin- seems to be the only expectorant that has clinical efficacy
27
Guaifenesin indications
expectorant
28
COPD Exacerbation
An acute event characterized by worsening of respiratory symptoms beyond normal day-to-day variations
* often leads to at least a temporary change in medications- may be a permanent change
29
Acute changes in cardinal symptoms of COPD Exacerbations
1. Cough increase in frequency and/or severity
2. sputum production increases in volume and/ or changes character
3. dyspnea increases
30
Why would a COPD Exacerbation lead to hospitalization
1. inadequate response to outpatient/ ED treatment
2. troublesome signs- cyanosis, altered mental status, peripheral edema
3. serious comorbidities- pneumonia, cardiac arrhythmia, heart failure, diabetes, renal/hepatic failure
4. frailty or insufficient home support
31
Home management of COPD
1. Ensure access to an inhaled short acting bronchodilator, with preference to a **SABA**
1. often times patients will require a short term titration up in dosing from 2 puffs q4-6 hours to 2 puffs q1-2 hours for a day or two
2. if having a severe exacerbation, it is likely more appropriate to use a nebulizer- more drug absorption and ease of administration
3. combo therapy is slightly more effective than either SABA alone
2. Continue use of LAMA/ LABA/ ICS
3. Consider systemic glucocorticoid administration - less likely to return to ED or their children within 30 days
1. prednisone - 40 mg daily for 5-14 days
2. short term glucocorticoid administration (up to 3 weeks), even at fairly high doses, do not need to be tapered
4. Antibiotics- use only in those who are likely to have bacterial infection- increased cough or purulence
1. mirrors antibiotic choices for pneumonia treatments
2. **azithromycin (and other macrolides)** particularly beneficial with COPD exacerbations
5. Antiviral- may initiate oseltamivir (tamiflu) for influenza positive patients
1. COVID antivirals?
32
Prednisone indications
Anti-inflammatory or immunosuppressant agent in the treatment of various diseases
33
MOA of Prednisone
Anti-inflammatory - suppress migration of polymorphonuclear leukocytes and reversal of increased **capillary permeability**
34
Contraindications Prednisone
Only a/w long term use- administration of live vaccines and systemic fungal infections
35
ADRs of Prednisone
Lots- but mostly a/w long term use-
Short term- agitation, aggression, hunger, insomnia, energy boost
36
Azithromycin Indications
1. Acute COPD Exacerbation and many others (GP, GN, Atypicals- **NO MRSA or Pseudomonas)**
37
MOA of Azithromycin
1. inhibits bacterial protein synthesis
1. exert **anti-inflammatory** effects by attenuated mucus secretion and decreased accumulation of PMN and MO in the airways- reduces inflammatory cytokine production
38
Contraindications Azithromycin
History of cholestatic jaundice/ hepatic dysfunction a/w prior azithromycin use
39
ADR of azithromycin
QT prolongation- increased risk of fatal heart rhythm
40
Oseltamivir Indications
1. Prophylaxis and treatment of influenza A or B
1. dosing must begin no later than 2 days after symptom onset
2. when started within 12 hours, symptom duration is reduced by 3 days, at 24 hours it is only reduced 2 days, and when started at 36 hours it is only reduced by 1.2 days
41
MOA of Oseltamivir
Inhibits virus neuraminidase- enzyme responsible foor cleaving budding viral progeny- prevents additional viruses from being released
42
ADR of Oseltamivir
GI Disturbances
43
How to treat a COPD exacerbation in the hospital
1. reversing airflow limitation with short acting bronchodilator- typically nebulized
2. systemic glucocorticoids
3. treat any underlying infections
4. sometimes nicotine replacement
5. VTE prophylaxis
44
Short acting bronchodilators - copd exacerbation
Should be nebulized
* continuous albuterol (10mg/ hr) inhalation- followed by 1 neb (2.5 mg) q2-4 hours prn
* albuterol/ ipratropium - dual effects with SABA/ SAMA
* continue LABAs/LAMAs/ ICS during exacerbation
45
Systemic glucocorticoids for COPD exacerbations
1. methylprednisolone is often used in hospital treatments
2. same duration as office/ at home treatment- 5-14 days
46
Treating underlying infections for COPD exacerbation
* similar to at home/ in office treatment- pneumonia antibiotics for suspected bacterial and oseltamivir for positive influenza
* start COVID meds if covid +
47
Nicotine Replacement for COPD exacerbation
reduce symptoms of withdrawal- typically done with nicotine patches unless a patient comes in on bupropion or varenicline
48
VTE prophylaxis for COPD exacerbation
enoxaparin 40 mg daily (30 mg for kidney dysfunction) or heparin 5000 units subq q8- q12 h (7500 units in morbidly obese)
49
Methylpredinsolone indications
similar to prednisone- many anti-inflammatory condiitions
50
Methyloprednisolone contraindications
Same as predisoone
51
Routes of methylprednisolone
1. iv route- 125 mg ONCE then 40-60 mg q6-12 hours
2. Oral tabs - Medrol dose pack
52
Methylprednisolone ADR
same as prednisone for short and long term ADR
