Bronchodilators and Antiasthmatics

Bronchodilators or antiasthmatics are medications used to

facilitate respiration by dilating the airways. They are helpful in
symptomatic relief or prevention of bronchial asthma and for
bronchospasm associated with COPD.

Table of Contents
 Bronchodilators and Antiasthmatics: Generic and Brand Names
 Disease spotlight: Bronchial Asthma
 Xanthines
 Therapeutic actions of Xanthines
 Indications
 Pharmacokinetics
 Contraindications and Cautions
 Adverse Effects
 Interactions
 Sympathomimetics
 Therapeutic Actions
 Indications
 Pharmacokinetics
 Contraindications and Cautions
 Adverse Effects
 Interactions
 Anticholinergics
 Therapeutic actions
 Indications
 Pharmacokinetics
 Contraindications
 Adverse effects
 Nursing Considerations for Bronchodilators
 Nursing Assessment
 Nursing Diagnosis and Care Planning
 Nursing Implementation with Rationale
 Evaluation
 Recommended Resources
 See Also
 We have a pill for that…
 References and Sources
Bronchodilators and Antiasthmatics: Generic and
Brand Names
Here are some of the most commonly encountered bronchodilators or
antiasthmatics, their generic names, and brand names.

 Xanthines
 aminophylline (Truphylline)
 caffeine
 dyphylline (Dilor)
 theophylline (Slo-Bid, Theo-Dur)
 Sympathomimetics
 albuterol (Proventil)
 arformoterol (Brovana)
 ephedrine
 epinephrine ( Sus-Phrine)
 formoterol (Foradil)
 indacaterol (Arcapta)
 isoetharine
 isoproterenol (Isuprel)
 levalbuterol (Xopenex)
 metaproterenol (Alupent)
 pirbuterol (Maxair)
 salmeterol (Serevent)
 terbutaline (Brethaire)
 Anticholinergics
 ipratropium (Atrovent)
 tiotropium (Sprival)
Disease spotlight: Bronchial Asthma
Asthma is characterized by reversible bronchospasm, inflammation,
and hyperactive airways.

 The hyperactivity is triggered by allergens or nonallergic inhaled

irritants, or by factors such as exercise and emotions.
 The trigger causes an immediate release of histamine, which
results in bronchospasm in about 10 minutes.
 The later response (3-5 hours) is cytokine-mediated
inflammation, mucus production, and edema contributing to
obstruction.
 Appropriate treatment depends on understanding the early and
late responses.
 The extreme case of asthma is called status asthmaticus; this is
life-threatening bronchospasm that does not respond to usual
treatment and occludes airflow into the lungs.
Xanthines
The xanthines come from a variety of naturally occurring sources.
These drugs were once the main treatment choices for asthma and
bronchospasm. However, because they have a relatively narrow
margin of safety and interact with many other drugs, they are no
longer considered the first-choice bronchodilators.

Therapeutic actions of Xanthines

The desired actions of xanthines include:

 A direct effect on the smooth muscles of the respiratory tract,

both in the bronchi and in the blood vessels.
 A theory suggests that xanthines work by directly affecting the
mobilization of calcium within the cell.
 They do this by stimulating two prostaglandins, resulting in
smooth muscle relaxation, which increases the vital capacity that
has been impaired by the bronchospasm or air trapping.
 Xanthines also inhibit the release of slow-reacting substance
of anaphylaxis and histamine, decreasing the
bronchial swelling and narrowing that occurs as a result of these
two chemicals.
Indications

Xanthines are indicated for the following:

 Relief of symptoms or prevention of bronchial asthma.

 Reversal of bronchospasm associated with COPD.
Pharmacokinetics

The xanthines are rapidly absorbed from the GI tract when given orally

Route Onset Peak Duration

Oral 1-6 h 4-6 h 6-8 h

IV Immediate 30 min 4-8 h

Half-life (T1/2) Metabolization Excretion

3 to 15 hours (nonsmoker), 4 to 5 hours (smoker) liver urine

Contraindications and Cautions

The following are contraindications and cautions when using xanthines:

  Co-morbidities. Caution should be taken with any patient with
GI problems, coronary disease, respiratory dysfunction, renal or
hepatic disease, alcoholism, or hyperthyroidism because these
conditions can be exacerbated by the systemic effects of
xanthines.
 Long-term parenteral use. Xanthines are available for oral and
parenteral use; the parenteral drug should be switched to oral
form as soon as possible because the systemic effects of the oral
form are less acute and more manageable.
 Pregnancy. Although no studies are available of xanthine effects
on human pregnancy, they have been associated with fetal
abnormalities and breathing difficulties at birth in animal studies,
so use should be limited to situations in which the benefit to the
mother clearly outweighs the potential risk to the fetus.
 Lactation. Because the xanthines enter breastmilk and could
affect the baby, another method of feeding the baby should be
selected if these drugs are needed during lactation.
Adverse Effects

Adverse effects from the use of xanthines include the following:

 CNS: Irritability, restlessness, dizziness.

 Cardiovascular: Palpitations, life-threatening arrhythmias.
 Others: Loss of appetite, fever, flushing.
 GU: Proteinuria.
 Respiratory: Respiratory arrest.
Interactions

Because of the mechanism of xanthine metabolism in the liver, many

drugs interact with xanthines.

 Nicotine. Nicotine increases the metabolism of xanthines in the

liver; xanthine dose must be increased in patients who continue
to smoke while using xanthines.
Sympathomimetics
 Sympathomimetics are drugs that mimic the effects of the
sympathetic nervous system.
 One of the actions of the sympathetic nervous system is dilation
of the bronchi with increased rate and depth of respiration.
  This is the desired effect when selecting a sympathomimetic as a
bronchodilator.
Therapeutic Actions

The desired actions of sympathomimetics include the following:

 At therapeutic levels, the action of most sympathomimetics are

specific to the beta-receptors found in the bronchi.
 Other systemic effects include increased blood pressure,
increased heart rate, vasoconstriction, and decreased renal and
GI blood flow- all actions of the sympathetic nervous system.
 Epinephrine, the prototype drug, is the drug of choice for adults
and children for the treatment of acute bronchospasm, including
that caused by anaphylaxis; it is also available for inhalation.
Indications

Sympathomimetics are indicated for the following:

 Long-acting treatment and prophylaxis of bronchospasm and

prevention of exercise-induced bronchospasm in patients 2 years
and older.
 Long-term maintenance treatment of bronchoconstriction in
COPD.
 Treatment of acute bronchospasm in adults and children,
although epinephrine is the drug of choice.
 Treatment and prophylaxis of acute asthma attacks in children
more than 6 years old.
Pharmacokinetics

Sympathomimetics are absorbed in many ways:

Route Onset Peak Duration

SC 5-10 min 20 min 20-30 min

IM 5-10 min 20 min 20-30 min

IV Instant 20 min 20-30 min

 Route Onset Peak Duration

Inhalation 3-5 min 20 min 1-3 h

Half-life (T1/2) Metabolization Excretion

unknown Normal neural pathways

Contraindications and Cautions

The following are contraindications and cautions when using

sympathomimetics:

 Underlying conditions. These drugs are contraindicated or

should be used with caution, depending on the severity of the
underlying condition, in conditions that would be aggravated by
the sympathetic stimulation, including cardiac disease, vascular
disease, arrhythmias, diabetes, and hyperthyroidism.
 Pregnancy and lactation. These drugs should be used during
pregnancy and lactation only if the benefits to the mother clearly
outweigh potential risks to the fetus or neonate.
Adverse Effects

Adverse effects when using sympathomimetics include the following:

 CNS: Headache, restlessness.

 Cardiovascular: Palpitation, tachycardia.
 Skin: Pallor, local burning and stinging.
 GU: Decreased renal formation.
 Respiratory: Rebound congestion with nasal inhalation.
 Misc: Fear, anxiety.
Interactions

Special precautions should be taken to avoid the combination of

sympathomimetic bronchodilators with the general anesthetics.
  Cyclopropane and halogenated hydrocarbons. Because
these drugs sensitize the myocardium to catecholamines, serious
cardiac complications could occur.
Anticholinergics
 Patients who cannot tolerate the sympathetic effects of
sympathomimetics might respond to the anticholinergic
drugs ipratropium (Atrovent) and tiotropium (Spiriva).
 These drugs are not as effective as the sympathomimetics but
can provide some relief to those patients who cannot tolerate the
other drugs.
Therapeutic actions

The desired effects of anticholinergics include:

 Anticholinergics are used as bronchodilators because of their

effect on the vagus nerve, which sis to block or antagonize the
action of the neurotransmitter acetylcholine at vagal-mediated
receptor sites.
 By blocking the vagal effect, relaxation of smooth muscle in the
bronchi occurs, leading to bronchodilation.
Indications

Anticholinergics are indicated for the following:

 Maintenance and treatment of bronchospasm for adults with

COPD.
 Long-term, once-daily maintenance and treatment of
bronchospasm associated with COPD in adults.
Pharmacokinetics

Anticholinergics are available for inhalation, using an inhaler device.

Route Onset Peak Duration

Inhalation 15 min 1-2 h 3-4 h

 Half-life (T1/2) Metabolization Excretion

unknown Neural pathways

Contraindications

The following are contraindications and cautions when using

anticholinergics:

 Co-morbidities. Caution should be used in any condition that

would be aggravated by the anticholinergic or atropine-like
effects of the drug, such as narrow-angle glaucoma, bladder neck
obstruction or prostatic hypertrophy, and conditions aggravated
by dry mouth and throat.
 Allergy. The use of ipratropium or tiotropium is contraindicated
in the presence of known allergy to the drug or to soy products or
peanuts to prevent hypersensitivity reactions.
 Pregnancy and lactation. These drugs are not usually
absorbed systematically, but as with all the drugs, caution should
be used in pregnancy and lactation because of the potential for
adverse effects on the fetus or nursing baby.
Adverse effects

Adverse effects when using anticholinergics include the following:

 CNS: Dizziness, headache.

 GI: Nausea, gastrointestinal distress.
 Cardiovascular: Palpitations.
 Respiratory: Cough.
 Misc: Nervousness.
Nursing Considerations for Bronchodilators
Nursing considerations for patients taking bronchodilators or
antiasthmatics include the following:

Nursing Assessment

History taking and physical examination of patients taking

bronchodilators or antiasthmatics.
  Assess for possible contraindications or cautions: any known
allergies to prevent hypersensitivity reactions; cigarette use
which affects the metabolism of the drug; peptic ulcer, gastritis,
renal or hepatic dysfunction, and coronary disease, all of which
could be exacerbated and require cautious use; and pregnancy
and lactation, which are contraindications because of the
potential for adverse effects on the fetus or nursing baby.
 Perform a physical examination to establish baseline data for
assessing the effectiveness of the drug and the occurrence of any
adverse effects associated with drug therapy.
 Perform a skin examination, including color and the presence of
lesions, to provide a baseline as a reference for drug
effectiveness.
 Monitor blood pressure, pulse, cardiac auscultation, peripheral
perfusion, and baseline electrocardiogram to provide a baseline
for effects on the cardiovascular system.
 Assess bowel sounds and do a liver evaluation and monitor liver
and renal function tests to provide a baseline for renal and
hepatic function tests.
 Evaluate serum theophylline levels to provide a baseline
reference and identify conditions that may require caution in the
use of xanthines.
 Evaluate urinary output and prostate palpation as appropriate to
monitor anticholinergic effects.
 Evaluate orientation, affect, and reflexes to evaluate CNS effects.
Nursing Diagnosis and Care Planning

Nursing diagnosis and care planning related to drug therapy include:

 Acute pain related to headache and GI upset.

 Disturbed sensory perception (kinesthetic, visual) related to
CNS effects.
 Deficient knowledge regarding drug therapy.
 Increased cardiac output related to sympathomimetic effects.
 Disturbed thought processes related to CNS effects.
 Imbalanced nutrition: less than body requirements related
to dry mouth and GI upset.
Nursing Implementation with Rationale

The nursing interventions for patients using bronchodilators or

antiasthmatics include:
 Relieve GI upset. Administer oral drug with food or milk to
relieve GI irritation if GI upset is a problem.
 Monitor drug response. Monitor patient response to the drug
(e.g., relief of respiratory difficulty, improved airflow) to
determine the effectiveness of the drug dose and to adjust dose
as needed.
 Provide comfort. Provide comfort measures including rest
periods, quiet environment, dietary control of caffeine, and
headache therapy as needed, to help the patient cope with the
effects of drug therapy.
 Provide follow-ups. Provide periodic follow-up, including blood
tests, to monitor serum theophylline levels.
 Individual drug response. Reassure patient that the drug of
choice will vary with each individual; these sympathomimetics
are slightly different chemicals and are prepared in a variety of
delivery systems; a patient may have to try several different
sympathomimetics before the most effective one is found.
 Proper administration and dosage. Advise the patient to use
the minimal amount needed for the shortest period necessary to
prevent adverse effects and accumulation of drug levels.
 Proper use of sympathomimetics. Teach the patients who use
one of these drugs for exercise-induced asthma to use it 30 to 60
minutes before exercising to ensure peak therapeutic effects
when they are needed.
 Use of adrenergic blockers. Alert the patient that long-acting
adrenergic blockers are not for use during acute attacks because
they are slower acting and will not provide the necessary rescue
in a state of acute bronchospasm.
 Increase oral fluid intake. Ensure adequate hydration and
provide environmental controls such as the use of a humidifier, to
make the patient more comfortable.
 Encourage voiding. Encourage the patient to void before each
dose of medication to avoid urinary retention related to drug
effects.
 Small, frequent meals. Provide small, frequent meals and
sugarless lozenges to relieve dry mouth and GI upset.
 Use of inhalator. Review the use of inhalator with the patient;
caution the patient not to exceed 12 inhalations in 24 hours to
prevent serious adverse effects.
 Educate the patient. Provide thorough patient teaching,
including the drug name and prescribed dosage measures to help
avoid adverse effects, warning signs that may indicate problems,
 and the need for periodic monitoring and evaluation, to enhance
patient knowledge about drug therapy and to promote
compliance.
 Provide patient support. Offer support and encouragement to
help the patient cope with the disease and the drug regimen.
Evaluation

Evaluation of a patient using bronchodilators/antiasthmatics include

the following:

 Monitor patient response to the drug (improved airflow, ease of

respirations, improved breathing).
 Monitor for adverse effects (CNS effects, increased pulse or blood
pressure, GI upset, dry skin, and mucous membranes).
 Evaluate the effectiveness of the teaching plan (patient can name
drug, dosage, adverse effects to watch for, specific measures to
avoid them, and measures to take to increase the effectiveness
of the drug).
 Monitor the effectiveness of other measures to ease breathing.