Corticosteroids
Corticosteroids produce anti-inflammatory action in the lungs by inhibiting cytokines and pro-inflammatory cells.
Indications: primary maintenance treatment for asthma
Administration: orally, IV, inhalation. Inhalation is the preferred route for respiratory treatment.
Contraindicated for acute exacerbations!
Long lasting. Most are given BID.
Commonly combined with LABAs in a single treatment.
Inhaled Corticosteroids — Reference
| Generic Name | Brand Name |
|---|---|
| Beclomethasone | Qvar |
| Flunisolide | Aerospan MDI |
| Fluticasone | Flovent MDI, Flovent Diskus |
| Budesonide | Pulmicort, Pulmicort Respules |
| Mometasone | Asmanex Twisthaler |
| Ciclesonide | Alvesco |
Inhalation Route
- First line maintenance and control therapy for chronic asthma and COPD
- Also prescribed if the patient is using SABA more than a few days per week
- Given if the patient is also waking up at night with SOB
Side Effects
- Decrease efficacy of hypertensive and diabetic medications
- Osteoporosis, cataracts, elevated BP, drug interaction, bleeding risk
- Potential growth retardation in pre-pubescents
Fungal Infections
- Candida Albicans — yeast infection (Thrush)
- Aspergillus Niger
Prevention:
- Utilize a holding chamber
- Rinse mouth post treatment
Corticosteroid + LABA Combinations
| Combination | Brand Name |
|---|---|
| Fluticasone + Salmeterol | Advair DPI & MDI |
| Mometasone + Formoterol | Dulera MDI |
| Budesonide + Formoterol | Symbicort MDI |
Nonsteroidal Anti-Asthma Agents
Primary indication: prophylactic management of mild persistent asthma
Used in conjunction with anti-inflammatory therapy.
Controller medication, not a symptom reliever or for acute exacerbations!
Asthma Inflammation Triggers
Extrinsic or Atopic (Environmental) — allergic hypersensitivity reactions to antigens
- Examples: pollen, dust, smoke, automobile exhaust, or animal dander
Intrinsic — non-allergic sensitivity; internal factors within the body that can initiate an inflammatory response, even in the absence of external threats like infection or injury.
Inflammatory Trigger Cascade
- Extrinsic trigger enters body (allergen sensitivity)
- Release of mediators target airway tissue (immune cells that promote inflammation)
- Inflammatory cells activated in airways
- Leukotrienes
- Histamine
- Prostaglandins
- Phosphodiesterase
Mast Cell Stabilizers
Cromolyn Sodium
Action: encapsulates the cell membrane making breach of the membrane more difficult — ultimately neutralizing release of inflammatory mediators (histamine, prostaglandins, leukotrienes).
Result: decreased severity and episodes in asthma and COPD exacerbation.
Anti-Leukotrienes
Zafirlukast (Accolate)
- Indication: prophylaxis and long-term treatment of asthma in patients 5 years and older
- Dose: x2 daily with LABA
Montelukast (Singulair)
- Indication: prophylaxis and long-term treatment of asthma in patients >12 months
- Dose: x1 daily
Zileuton (Zyflo)
- Indication: prophylaxis and long-term treatment of asthma in patients 12 years and older
- Dose: 600 mg tablet QID; two extended-release tablets BID
- Liver damage susceptibility — liver enzymes checked regularly!
Monoclonal Antibody (Anti-IgE)
Omalizumab (Xolair)
Indications:
- Moderate or greater perennial allergic asthma
- Patients >12 years and not controlled with inhaled steroids
Administered: subcutaneous injection q2–4 weeks
Action: prevents IgE (immunoglobulin E) from attaching to mast cells (blocks IgE).
Phosphodiesterase Enzyme (PDE4) Inhibitor
Roflumilast
Indication: inhibit the inflammatory response associated with COPD exacerbations
Action: increases cAMP, produces long-acting inhibition of the PDE4 enzyme. By increasing cAMP, we suppress pro-inflammatory pathways.
Administration: oral
Anti-Infective Agents
Treatments for Pneumonia
Quinolones
Treat Gram+/- bacteria. A more broad-spectrum type of antibiotic.
- Ciprofloxacin
- Levofloxacin
- Moxifloxacin
- Gemifloxacin
Macrolides
Treat Gram+ bacteria and limited Gram- bacteria.
- Azithromycin
- Clarithromycin
- Erythromycin
Anti-Infective Inhaled Aerosol — Reference
| Generic Name | Brand Name |
|---|---|
| Pentamidine | Nebupent |
| Tobramycin | Tobi |
| Gentamicin | — |
| Aztreonam | Cayston |
| Amphotericin B | — |
| Zanamivir | Relenza |
| Ribavirin | Virazole |
Pentamidine (Nebupent)
Indication: prophylactic therapy for Pneumocystis Carinii Pneumonia (PCP) common in AIDS infected patients
Negative effects: bronchospasm, shortness of breath, and bronchial irritation
Bronchodilator pre-treatment may reduce symptoms.
Administration: nebulized solution
- Utilize negative airflow rooms with HEPA filtration
- Respirgard II nebulizer — protects care environment
- N-95 mask and full PPE worn by providers
Ribavirin (Virazole)
Indication: infants with severe Respiratory Syncytial Virus (RSV)
Administration: Small Particle Aerosol Generator (SPAG-2)
Precautions:
- Utilize negative airflow rooms with HEPA filtration
- Negative side effects — exposure concerns to providers (GI, CNS, hematologic)
Tobramycin (Tobi)
Indication: Chronic Pseudomonas Aeruginosa (common treatment for CF patients) — Gram negative organism
Dose: adults and children >6 yrs — 300 mg in 5 mL, x2 daily
- Not mixed with other medications
- Last medication of each therapy visit
Administration: nebulized solution. Use negative airflow rooms with HEPA filtration.
Inhaled negative effects:
- Teratogenic effects — fetal abnormalities risk during pregnancy
- Voice alteration and tinnitus
- Ototoxicity — hearing loss with prolonged use
- Nephrotoxicity — impaired renal function
Aztreonam (Cayston)
Indication: Chronic Pseudomonas Aeruginosa
Administration:
- Not recommended for children younger than 7 years of age
- May cause bronchospasm and decrease in FEV1
Pretreatment with a bronchodilator is recommended.
Gentamicin
Indication: Pseudomonas Aeruginosa (common with CF)
Amphotericin B
Indication: pulmonary fungal infections (transplants)
- Aspergillosis
- Candida Albicans
Zanamivir (Relenza)
Indication: influenza in adults and children older than 5 years of age within the first 2 days of infection
Mode: DPI / Diskhaler
Dose: two inhalations — 5 mg each, Q 12 hrs/BID for 5 days
Negative effects:
- Bronchospasm
- Not recommended for patients with underlying airway disease
Pneumovax — Pneumococcal Vaccine
Indications:
- Protects against influenza bacteria
- Protects against Streptococcus Pneumoniae
Immunization annually: health care providers, children, people with risk of aspiration, school and work communities, individuals predisposed to environmental risk
Contraindications: allergy sensitivity (rare)
Cold and Cough Agents
Antihistamines
Secretion modifiers: medications that inhibit mucus production and/or modify mucus rheology or consistency.
Indication: reduce the volume of secretions associated with upper airway diseases and allergies
Effects: produces strong, long acting, drying effect
Medications:
- Allegra, Zyrtec and Claritin — non-sedating
- Benadryl (Diphenhydramine) — sedating effect
Pulmonary Vasodilators
Inhaled Nitric Oxide (INOmax)
Indication:
- Persistent Pulmonary Hypertension in Neonates (PPHN) >34 wks
- Decreases need for ECMO
Off label benefits (NOT FDA approved):
- Acute pulmonary hypertension in adults
- ARDS — Acute Respiratory Distress Syndrome
- Post lung transplant perfusion
- Reduce pulmonary vascular resistance (PVR)
- Reduce pulmonary artery pressure (PAP)
Treatment: normally for 14 days or less
Delivery modalities:
- Inline mechanical ventilator life support (primary mode)
- High flow NC (Vapotherm) — neonates and adults
Recommended dose: less than 20 ppm
Risks
- Methemoglobin — a ferric (Fe3+) hemoglobin molecule and cannot bind with oxygen
- Slow weaning — prevent rebound
Prostacyclin
- Iloprost (Ventavis)
- Treprostinil (Tyvaso)
- Epoprostenol Sodium (Flolan)
Skeletal Muscle Relaxants (Neuromuscular Blocking Agents)
NMBAs
Indications:
- Facilitate intubation (paralyze vocal cords)
- Surgery — immobilize patients
- Enhance ventilator synchrony
- Reduce intracranial pressure (ICP)
- Reduce O2 consumption
NMBAs work to paralyze and relax skeletal muscles. Affects skeletal muscle only.
Depolarizing Agents
Succinylcholine — only agent in this category
Action: OCCUPIES acetylcholine receptors
- Paralysis in 60–90 seconds
- Effect persists for 10–15 minutes
- Ideal for patients requiring intubation
No reversal agent!
Adverse Effects
- Dry eyes
- Tachycardia
- Hypotension
- Malignant hyperthermia
- Muscle pain and muscle weakness
- Hyperkalemia — efflux of potassium from muscle cells
- Effects of severe hyperkalemia include arrhythmias and cardiac arrest
Non-Depolarizing Agents
Action: BLOCK acetylcholine receptors
- Longer duration than depolarizing agent — approximately 30 minutes
- Preferred for paralysis of mechanically ventilated patients
- Onset varies — dosage dependent: >5 minutes
Non-depolarizing agents:
- Rocuronium
- Vecuronium
- Pancuronium
Reversal agent: Neostigmine
Adverse Effects
- Inadequate ventilation — paralysis of diaphragm and intercostal muscles
- Cardiovascular — vagolytic effect triggers tachycardia; increase in mean arterial pressure (MAP). Pancuronium has greatest potential for cardiovascular side effects.
- Histamine release — histamine release from mast cells triggers hypotension
Diuretic Agents and Fluid Resuscitation
Urine Output
- Normal: 30 to 60 mL/hr
- Anuria: no urine output (sign of renal failure)
- Oliguria: less than 30 to 60 mL/hr
- Polyuria: >60 mL/hr
Diuretics
Indications:
- IV resuscitation fluid overload
- Congestive Heart Failure
- Hypertension
- Pulmonary edema, cerebral edema (TBI), renal dysfunction
Contraindications: hypovolemia, pregnancy and women breast feeding
Diuretic effects:
- Stimulate urine production
- Eliminates excess extracellular fluid volume
- Reduces blood pressure
Side effects: hypovolemia, acid-base abnormalities
Common Diuretics
| Category | Medications |
|---|---|
| Carbonic Anhydrase Inhibitor | Acetazolamide, Methazolamide, Dichlorphenamide |
| Osmotic | Mannitol, Glycerol, Urea |
| Loop | Furosemide (Lasix) — most commonly used for CHF! |
| Thiazide | Chlorothiazide, Hydrochlorothiazide |
| Potassium Sparing | Amiloride, Spironolactone |
Fluid Resuscitation
Indications:
- Hypotension
- Hypovolemia
- Postural Hypotension
- Shock
Treatments:
- Fluids — intravenous and oral rehydration. Give blood products, colloids etc.
- Chemical — vasopressor agents (norepinephrine, dopamine etc.)
- Patient placed in Trendelenburg position
Hypotension
Hypotension — blood pressure less than 90/65 mmHg
NOT SYNONYMOUS WITH SHOCK!
Hypotension caused by dehydration (hypovolemia) and is reversed by rehydration.
Hypovolemia
Decreased blood volume.
Causes:
- Initiation of diuretic treatment or increased dose
- Reduced dietary sodium intake
- Diarrhea or excessive sweating
- Ingesting drugs that impair diuretic administration
Indications: sinus tachycardia; decreased CO and SV; dizziness, extreme thirst, excessive mouth dryness, decrease or dark urine output, constipation
Postural Hypotension
Indication: dizziness upon standing or abruptly sitting up, caused by reduced cerebral blood flow.
- Healthy individuals with mild hypovolemia
- Syncope if more serious (fainting)
- Medication side effects/interactions
Verification method: measure blood pressure in the supine and sitting positions or standing up
Shock
Shock — inadequate delivery of O2 and nutrients to vital organs relative to their metabolic demand.
- Hypo-dynamic: cardiogenic; hypovolemic
- Hyper-dynamic: vascular; septic; anaphylactic
Resuscitation Fluids
Colloid — Volume Expanders
Large molecule solution — incapable of crossing the healthy semipermeable capillary membrane owing to the molecular weight/size of the molecules.
- Human Albumin (4 to 5%) in saline
- Hydroxyethyl Starch (HES)
Crystalloid — Carrier and Expander
Small molecule solution — flow crosses semipermeable membrane allowing transfer from bloodstream into cells and body tissues.
- Normal saline (0.9%) — most common