RESPIRATORY PROBLEMS

Asthma
Chronic Obstructive Pulmonary Disease
Acute Respiratory Distress Syndrome
Drug-Induced Pulmonary Diseases
Cystic Fibrosis
 ASTHMA
• Asthma is a disease of increasing prevalence that
is a result of genetic predisposition and
environmental interactions.
• Asthma is primarily a chronic inflammatory
disorder of the airways of the lung characterized
by T-helper cell type 2 (Th2)–lymphocyte–
mediated immune response for which there is no
known cure or primary prevention
• Asthma is characterized by either the intermittent
or persistent presence of highly variable degrees
of airway obstruction rom airway wall
inflammation and bronchial smooth muscle
constriction.
• The inflammatory process in asthma is treated most
effectively with corticosteroids, with the inhaled
corticosteroids having the greatest efficacy for persistent
asthma.
• Bronchial smooth muscle constriction is prevented or
treated most effectively with inhaled β2-adrenergic
receptor agonists.
• Variability in response to medications requires
individualization
• of therapy within existing evidence-based guidelines for
management.
• Ongoing patient education, including avoidance of triggers
• and self-management techniques, is essential for optimal
• patient outcomes
 ETIOLOGY
• Respiratory infection
• Respiratory syncytial virus (RSV), rhinovirus, influenza,
• parainfluenza, Mycoplasma pneumonia
• Allergens
• Airbone pollens (grass, trees, weeds), house-dust mites, animal
• danders, cockroaches, fungal spores
• Environment
• Cold air, fog, ozone, sulfur dioxide, nitrogen dioxide, tobacco smoke, wood smoke
• Emotions
• Anxiety, stress, laughter
• Exercise
• Particularly in cold, dry climate
• Drugs/preservatives
• Aspirin, NSAIDs (cyclooxygenase inhibitors), sulfites, benzalkonium chloride, β-
blockers
• Occupational stimuli
 TREATMENT: Asthma
• AEROSOL THERAPY FOR ASTHMA
Aerosol delivery of drugs for asthma has the advantage of being site-
specific and thus enhancing the therapeutic ratio.2,24 Inhalation of
short-acting β2-agonists provides more rapid bronchodilation than
either parenteral or oral administration, as well as the greatest
degree of protection against EIB and other challenges.25
• Inhaled corticosteroids produce a greater reduction of BHR than
corticosteroids administered systemically.2 Specific agents (e.g.,
cromolyn, nedocromil, formoterol, salmeterol, and ipratropium) are
only effective by inhalation.2,24 Given the international ban on the
production and use of chlorofluorocarbons (CFCs), the
manufacturers of CFC-propelled metered-dose inhalers (MDIs) are
developing new devices for delivering topically active
medication.2,24 Therefore, an understanding of aerosol drug
delivery is essential to optimal asthma therapy. Table 26–4 lists the
factors determining lung deposition of therapeutic aerosols.
TREATMENT: Severe Acute Asthma
the principal goals of treatment include:
• Correction of significant hypoxemia
• Rapid reversal of airflow obstruction
• Reduction of the likelihood of recurrence of
severe airflow obstruction
• Development of a written action plan in case
of a further exacerbation
 Inhaled β-agonists
• Albuterol nebulizer soln.(5 mg/mL)
2.5–5 mg every 20 min for 3 doses, then 2.5–10 mg
every 1–4 h as needed, or 10–15 mg/h continuously
• 0.15 mg/kg (minimum dose 2.5 mg) every 20 min
for 3 doses, then 0.15–0.3 mg/kg up to 10 mg every
1–4 h as needed, or 0.5 mg/kg/h by continuous
nebulization
• Only selective β2-agonists are recommended
• For optimal delivery, dilute aerosols to minimum of
4 mL at gas flow of 6–8 L/min
 Inhaled β-agonists
Albuterol nebulizer soln.(5 mg/mL)
>6 Years old:
• 2.5–5 mg every 20 min for 3 doses, then 2.5–10 mg
every 1–4 h as needed, or 10–15 mg/h continuouslyars
• <6 years old:
• 0.15 mg/kg (minimum dose 2.5 mg) every 20 min for 3
doses, then 0.15–0.3 mg/kg up to 10 mg every 1–4 h as
needed, or 0.5 mg/kg/h by continuous nebulization
• Albuterol MDI (90 mcg/puff)
• Levalbuterol nebulizer soln.
• Bitolterol nebulizer soln. (2 mg/mL)
• Pirbuterol MDI (200 mcg/puff)
 Systemic β-agonists
• Epinephrine 1:1000 (1 mg/mL)
0.3–0.5 mg every 20 min for 3 doses SQ
• Terbutaline (1 mg/mL) 0.25 mg every 20 min
for 3 doses SQ
 Anticholinergics
Ipratropium Br
nebulizer soln. (0.25 mg/mL)
500 mcg every 30 min for 3 doses, then every
2–4 h as needed
 Corticosteroids
• Prednisone,
• methylprednisolone,
• Prednisolone
• 60–80 mg in 3 or 4 divided doses for 48 h,
then 30–40 mg/day until PEF reaches 70% of
personal best
 PHARMACOTHERAPY
Relative Selectivity, Potency, and Duration of
Action of the β-Adrenergic Agonists
 Selectivity
beta1 beta2
• Isoproterenol ++++ ++++
• Roterenol +++ +++
• Isoetharine ++ +++
• Albuterol + ++++
• Bitolterol + ++++
• Pirbuterol + ++++
• Terbutaline + ++++
• Formoterol + ++++
• Salmeterol + ++++