Respiratory System

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Respiratory System

• Chapter 43

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Respiration

• Process of air exchange
• Oxygen is obtained and carbon dioxide is
  eliminated
• Gas exchange occurs the alveolar capillary
  membrane

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Four parts of respiration

• Ventilation movement of air between the
  atmosphere and alveoli
• Perfusion blood flow through the lungs
• Diffusion oxygen and carbon dioxide are
  transferred between alveoli and blood
• Regulation respiratory muscles and nervous
  system

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Respiratory Tract

• Nose, pharynx, larynx, trachea, bronchi
• Series of tubes that function as airway passages
• Filter, warm and humidify incoming air

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Pharynx

• Contain the tonsils normal function is to fight
  infection
• Larynx voice box

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Epiglottis

• Flexible cartilage supported flap that covers
  the opening of the trachea or (glottis)
• It automatically closes the opening to the
  trachea during swallowing
• If you eat food to fast it can get lodged in the
  trachea

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Heimlich Maneuver

• Used to pop food out and back into the pharynx

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Heimlich Maneuver
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Trachea

• Trachea is lined with ciliated columnar
  epithelium and mucous cells
• The chronic cough of smokers is caused by lack of
  cilia.

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Lungs

• Right side has 3 lobes
• Left side 2 lobes
• Contain the lower respiratory structures

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Bronchi and Bronchioles

• Bronchi will contract with simulation causing one
  to cough

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Alveoli

• Have a very thin membrane that allows rapid
  diffusion of oxygen and carbon dioxide between
  capillary blood and alveolar air spaces
• Lined with surfactant to prevent alveolar
  collapse
• Lack of surfactant is a real problem in premature
  infants

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Surfactant

• Essential fluid that lines the alveoli and
  smallest bronchioles.
• Reduces surface tension of the lung allowing the
  oxygen and carbon dioxide across the membrane

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Oxygen Exchange
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Lack of Surfactant
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Nervous System Role

• Nervous system regulates the rate and depth of
  respirations
• Medulla oblongata is the respiratory control
  system of the brain
• Cough reflex is stimulated by NS

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Disorders of Respiratory System

• Infections
• Allergic disorders
• Inflammatory disorders
• Obstructive airway disorders
• Bronchial pulmonary dysplasia premature infants
• Asthma
• Chronic obstructive pulmonary diseases
• Injury to lungs

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Drugs for Asthma and Broncho-constrictive
Disorders

• Chapter 44

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Asthma

• Airway disorder characterized by
• Hyper-reactivity to various stimuli - trigger
• Broncho-constriction
• Inflammation

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Clinical Manifestations

• Dyspnea difficulty breathing
• Wheezing
• Chest tightness
• Cough chronic cough may be the only symptom
• Sputum production

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Precipitating Factors - Triggers

• Viral infections especially with infants and
  young children
• Allergies
• GERD
• Cigarette smoke
• Smoggy air smoke from fires
• Windy weather hot and dry Santa Ana winds

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Pathophysiology

• Broncho-constriction or bronchospasm
• Spasm aggravated by inflammation, mucosal edema
  and excessive mucus
• Mast cells release substances that cause
  inflammation and constriction
• Acute reaction to some trigger reversible with
  treatment

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Drug to Treat Asthma
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Quick Relief

• Short-acting, inhaled, beta 2 agonist, 2-5 puffs
  as needed

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Albuterol, levalbuterol, pirbuteral

• Rescue drug short acting beta2- adrenergic
  agonist used for prevention and treatment of
  bronchocontriction
• Acts selectively on beta2 receptors and cause
  less cardiac stimulation than epinephrine

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Albuterol

• Provided in extended-release tablet
• Albuterol syrup
• Nebulizer or dry powder inhaler
• Often used in exercise induced asthma
• Take 15 minutes before exercise

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Albuterol
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Albuterol
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Albuterol INH - Nebulizer
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Directions for use of inhaler

• Shake well
• Exhale (breathe out) through your nose while
  keeping mouth shut
• Close lips around mouth piece
• Take slow, deep breath through the mouthpiece as
  you press down on container to release the
  medication
• Hold breath for 5-10 seconds
• Exhale slowly

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Teaching

• May give up to 3 treatments at 20 minute
  intervals
• If no relief need to call PMD or go to ED

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Long Term Control

• Mild-intermittent
• Symptoms 2 days/week or less
• Treat acute exacerbations with
• Beta 2 agonist
• Short course of systemic corticosteroid
  prednisone

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Mild Persistent Asthma

• Low-dose inhaled corticosteroids
• Leukotriene modifier
• Theophylline PO

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Moderate Persistent Asthma

• Daily symptoms
• Inhaled corticosteroids
• Long-acting beta 2 agonist
• Leukotriene or theophylline

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Corticosteroids

• Long term control of asthma
• Inhaled by Nebulizer or metered dose inhaler
• For an infant hold the Nebulizer with a firm
  fitting mask to the infant or small childs face
• Metered dose have client rinse and spit after
  dose to avoid developing thrush

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Action

• Suppress inflammation in the airways by
  inhibiting
• Movement of fluid and protein into tissues
• Migration and function of neutrophils and
  eosinophils WBCs
• Synthesis of histamine in mast cells
• Production of pro-inflammatory substances

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Uses

• Severe asthma used when multiple doses of
  inhaled beta2 agonists are not beneficial
• PO prednisone
• IV methyl prednisone
• In chronic asthma inhaled
• COPD not as effective as the acute / chronic
  asthma

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When to call MD or go to ED

• Tight chest wheezing difficulty breathing
• Symptoms not relieved by home meds
• 3 treatments with short-acting beta 2 agonist
  such as albuterol with no relief

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Epinephrine

• Given in the office or ED
• Injected sub Q during an acute attack
• Therapeutic effects within 5 minutes
• Last for about 4 hours

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Epinephrine 1 to 10,000 or 0.1 mg/mL
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Epinephrine 11000 - 1 mg/mL
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Hospital Treatment

• Albuterol q 4 hours
• Methylprednisone IV
• IV fluids
• Antibiotics only if documented pneumonia
• Oxygen to keep oxygen saturations to gt 94
• Assess lung sounds every four hours and before
  and after albuterol treatments

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Hyper-inflated Lungs in Asthma
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COPD - Chronic Bronchitis

• COPD more of a chronic disease due to long-term
  exposure to airway irritants such as smoking
• Broncho-constriction and inflammation are more
  constant and less reversible
• Changes have occurred over the years
• Blue Bloaters they are often cyanotic

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COPD
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COPD - Emphysema

• Loss of elasticity of the lung tissue
• Destruction of structures supporting the alveoli
  and capillaries feeding the alveoli
• Air trapping at the alveolar level
• Pink Puffers hyperventilate to maintain
  adequate oxygen levels this prevents hypoxia

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Emphysema
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COPD - Clinical Manifestations

• Dyspnea difficulty breathing
• Activity intolerance
• Cough and sputum production
• Progressive

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Drug Therapy

• Two major drug groups
• Bronchodilators
• Anti-inflammatory drugs

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Mild COPD

• Short acting beta 2 agonist
• Cessation of smoking
• Immunization against flu

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Moderate COPD

• Add one or more long-acting bronchodilators such
  as salmetrol or formoterol
• Inhaled Anticholinergic drugs such as Atrovent
• PO Theophylline

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Ipratropium or Atrovent

• Anticholinergic taken by inhalation for
  maintenance therapy of bronchocontriction
  associate with chronic bronchitis and emphysema.
• Improved pulmonary function in a few minutes
• Available as nasal spray

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Inhaled corticosteroids

• Somewhat controversial
• Some evidence that inhaled corticosteroids
  symptoms but do not effect rate of decline in
  pulmonary function

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Unwanted Side Effects

• Cardiac stimulation
• Contraindicated in clients with hypertension,
  hyperthyroidism, diabetes and seizure disorders

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Xanthines - Theophylline

• Theophylline mechanism of action unknown
• Used in COPD and sometimes asthma
• Inhibits pulmonary edema by decreasing vascular
  permeability
• Increases ability of cilia to clear mucus
• Strengthens contractions of diaphragm
• Decreases inflammation
• Mild diuretic

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Side Effects - Complications

• Stimulates the CNS
• Need to monitor heart rate
• Serum blood levels need to be monitored -
  therapeutic versus toxic dose
• Normal serum blood levels 5 to 15 mcg / mL

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Leukotriene Modifiers

• Newest class of drugs to treat asthma
• Block the production of leukotrienes and
  subsequently prevent inflammation
• Drugs in this class
• Singulair chewable tabs take once a day in the
  evening
• Accolate take twice daily one hour before or
  two hours after meal

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Mast Cell Stabilizer

• Cromolyn
• Prevent the release of broncho-constrictive and
  inflammatory substances when mast cells are
  confronted with allergens and other stimuli
• Inhaled drug
• Nasal form available for allergic rhinitis

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Toxicity of Drugs

• Bronchodilators
• Theophylline

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Bronchodilator Overdose

• Excessive cardiac and CNS stimulation
• Angina, tachycardia and palpitations
• Agitation, anxiety, insomnia, seizures and tremors

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Theophylline Overdose

• Anorexia, nausea, vomiting, agitation,
  nervousness, insomnia, tachycardia, and
  convulsions
• Need to check serum drug levels
• Not use as frequently as in the past

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Antihistamines and Allergic Disorders

• Chapter 45

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Histamines

• First chemical mediator to be released in immune
  and inflammatory response
• Released from mast cells and basophils in
  response to certain stimuli

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Action

• Contraction of smooth muscle in the bronchi and
  bronchioles
• Stimulation of vagus nerve cough reflex
• Increases permeability of veins and capillaries
• Increase secretion of mucous glands
• Dilation of capillaries of skin causes flushing

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Types of Allergic Reactions

• Type I immediate hypersensitivity occurs
  within minutes of exposure
• Type II mediated by IgG or IgM
• Type III antigen-antibody complex
• Type IV occurs several hours after exposure

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Allergic Rhinitis

• Inflammation of nasal mucosa caused by Type I
  hypersensitivity.
• Two types
• Seasonal
• Perineal or chronic

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Allergic Dermatitis

• Type IV by direct contact with antigens which
  person has come in contact with
• Poison Ivy, cosmetics, hair dyes, metals, drugs
  etc
• Urticaria vascular reaction of skin
  characterized by papules or wheals and severe
  itching

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Urticaria
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Allergic Drug Reactions

• Immunologic response
• Follows ingestion of a drug
• May occur from 7 to 10 days after drug therapy
• May not occur the first time drug administered
• Can occur minutes or hours after administration

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Anaphylaxis Life-threatening allergy

• Serious and rapid allergic reaction
• Can happen from food and nuts
• Antibiotics penicillin
• Dyes injected into the body in special tests
• NSAIDs
• Latex gloves, balloons, catheters
• Bees or wasps

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Anaphylaxis Symptoms

• Urticaria, hives
• Low blood pressure fainting
• Swelling in throat angioedema
• Asthma symptoms bronchocontriction
• Tingling in lips and mouth
• Death occurs with obstruction to breathing and
  low blood pressure

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Treatment

• Adrenaline epinephrine
• Dose for adult 0.3 mg
• Dose for child 0.15 mg
• After dose given must get client to the hospital
  for more definitive treatment.

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Antihistamines

• Inhibits smooth muscle constriction in blood
  vessels and the respiratory and GI tract
• Decreases capillary permeability
• Decrease salivation and tear formation

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Action

• Effective in inhibiting vascular permeability,
  edema formation, bronchocontriction and purities
  (itching)

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Uses

• Allergic rhinitis
• Anaphylaxis
• Allergic conjunctivitis
• Drug allergies
• Blood transfusion reactions
• Dermatologic conditions

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H1 receptor antagonists

• First generation
• Non-selective or sedating
• CNS depression
• Benadryl

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Benadryl

• High incidence of drowsiness
• Well absorbed after oral administration
• Acts within 15 minutes and lasts for 8 to 12
  hours
• Available in combination drugs
• Decongestants
• Analgesics
• Allergy
• Cold remedies

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Hydroxyzine - Atarax

• Antihistamine with Anticholinergic (drying) and
  sedative properties
• Prevent histamine from stimulating the cells
• Uses relief of nasal symptoms aid in insomnia

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Nasal Decongestant, Antitussive and Cold Remedies

• Chapter 46

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Common Cold

• Viral infection of upper respiratory tract
• Adults have two to four colds per year
• Children can have up to ten a year

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Management of common cold

• Symptoms cough, runny nose, blocked nose, sore
  throat, fever, malaise, headache, loss of
  appetite.
• No antibiotics unless super-imposed bacterial
  infection otitis media (ear infection)
• No drug therapy to cure or shorten duration of
  URI.
• No benefit of using anti-histamines

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Cold Remedies

• Antihistamines Allegra, Benadryl, Claritin,
  Clarinex, Zyrtec
• Decongestants cause constriction of swollen
  blood vessels in nose, sinuses and chest
• Sudafed most often used in combination

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Cough

• Coughing is a protective reflex especially when
  secretions are copious.
• Most coughs due to viral illness common cold.

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Cough Remedies

• Centrally acting cough suppressants
• Antihistamines
• Soothing remedies (syrup or lozenges)
• Expectorants
• Mucolytic
• Oral hydration
• Mist therapy

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Antitussive Drugs

• Cough Suppressants
• Suppress cough by depressing the cough center of
  the medulla oblongata or cough receptors in the
  throat
• Indication hacking cough that interferes with
  sleep

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Anti-histamines

• H1-receptor inhibitors
• Anti-allergy
• Added to cough and cold remedies as both
  antitussives and to treat the nasal congestion.
• Do not have any direct antitussive effect but may
  act indirectly by reducing postnasal drip.

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Demulcents

• Liquid that coats the throat and soothes
  irritated mucous membranes.
• May reduce coughing associated with a dry throat.
• Some cough syrups contain 40 alcohol may have
  a sedating effect.
• Inexpensive
• Do not over use

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Clearing thick mucous

• Expectorants
• Mucolytics

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Expectorants

• Aim to stimulate bronchial mucous production,
  making the secretions easier to remove by cough
  or by ciliary transport.
• Expectorants are generally sold in combination
  with decongestants and antihistamines.

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Mucolytic Drugs

• Designed to alter the viscosity of bronchial
  secretions, thereby making them easier to clear
  by cough or ciliary transport.
• Often used when client reports they feel like
  they have mucous by cant cough it up.

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Nasal Sprays

• Nose sprays decongestant for direct application
  to nares
• Has bounce back effect do not use for more than
  three days