Drugs Affecting The Respiratory System

Drugs Affecting the
Respiratory System
Antihistamines,
Decongestants,
Antitussives,
and
Expectorants
Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Understanding the Common Cold
• Most caused by viral infection

(rhinovirus or influenza virus—the “flu”)

• Virus invades tissues (mucosa) of upper

respiratory tract, causing upper respiratory
infection (URI).
• Excessive mucus production results from the
inflammatory response to this invasion.
• Fluid drips down the pharynx into the
esophagus and lower respiratory tract,
causing cold symptoms: sore throat,
coughing, upset stomach.
• Irritation of nasal mucosa often triggers the

sneeze reflex.
• Mucosal irritation also causes release of
several inflammatory and vasoactive
substances, dilating small blood vessels in
the nasal sinuses and causing nasal
congestion.

Treatment of the Common Cold
• Involves combined use of antihistamines,

nasal decongestants, antitussives, and
expectorants.
• Treatment is SYMPTOMATIC only, not
curative.
• Symptomatic treatment does not eliminate
the causative pathogen.

Instructors may want to use
EIC Image #83:
Upper Respiratory Tract

Treatment of the Common Cold
• Difficult to identify whether cause is viral or

bacterial.
• Treatment is “empiric therapy,” treating the
most likely cause.
• Antivirals and antibiotics may be used, but
viral or bacterial cause may not be easily
identified.

Antihistamines
Drugs that directly compete with histamine

for specific receptor sites.
• Two histamine receptors:
– H1 histamine-1
– H2 histamine-2

Antihistamines
H2 Blockers or H2 Antagonists
– Used to reduce gastric acid in PUD
– Examples: cimetidine (Tagamet),
ranitidine (Zantac), or
famotidine (Pepcid)

Antihistamines
H1 antagonists are commonly referred

to asantihistamines
• Antihistamines have several effects:
– Antihistaminic
– Anticholinergic
– Sedative

Antihistamines: Mechanism of Action
BLOCK action of histamine at the receptor sites

• Compete with histamine for binding at unoccupied
receptors.
• CANNOT push histamine off the receptor if already
bound.

• The binding of H1 blockers to the histamine

receptors prevents the adverse
consequences of histamine stimulation:
– Vasodilation
– Increased gastrointestinal and respiratory
secretions
– Increased capillary permeability

• More effective in preventing the actions of

histamine rather than reversing them
• Should be given early in treatment, before
all the histamine binds to the receptors

Histamine vs. Antihistamine Effects
Cardiovascular (small blood vessels)

• Histamine effects:
– Dilation and increased permeability
(allowing substances to leak into tissues)
• Antihistamine effects:
– Prevent dilation of blood vessels
– Prevent increased permeability

Smooth Muscle (on exocrine glands)

– Stimulate salivary, gastric, lacrimal, and
bronchial secretions
• Antihistamine effects:
– Prevent salivary, gastric, lacrimal, and
bronchial secretions

Immune System
(Release of substances commonly
associated with allergic reactions)
– Mast cells release histamine and other
substances, resulting in allergic reactions.
• Antihistamine effect:
– Binds to histamine receptors, thus preventing
histamine from causing a response.
Antihistamines: Other Effects
Skin:
• Block capillary permeability, wheal-and-flare
formation, itching
Anticholinergic:
• Drying effect that reduces nasal, salivary, and
lacrimal gland secretions (runny nose, tearing, and
itching eyes)
Sedative:
• Some antihistamines cause drowsiness
Antihistamines: Therapeutic Uses
Management of:
• Nasal allergies
• Seasonal or perennial allergic rhinitis

(hay fever)
• Allergic reactions
• Motion sickness
• Sleep disorders

Antihistamines
10 to 20% of general population is sensitive
to various environmental allergies.
• Histamine-mediated disorders:
– Allergic rhinitis
(hay fever, mold and dust allergies)
– Anaphylaxis
– Angioneurotic edema
– Drug fevers
– Insect bite reactions
– Urticaria (itching)
Antihistamines: Therapeutic Uses
Also used to relieve symptoms associated

with the common cold:
• Sneezing, runny nose
• Palliative treatment, not curative

Antihistamines: Side effects
• Anticholinergic (drying) effects, most
common:
– Dry mouth
– Difficulty urinating
– Constipation
– Changes in vision
• Drowsiness
– (Mild drowsiness to deep sleep)
Antihistamines: Two Types
• Traditional
or
• Nonsedating/Peripherally Acting

Antihistamines:
Traditional
• Older
• Work both peripherally and centrally
• Have anticholinergic effects, making them more
effective than nonsedating agents in some cases
Examples: diphenhydramine (Benadryl)
chlorpheniramine (Chlor-Trimeton)

Antihistamines:
Nonsedating/Peripherally Acting
• Developed to eliminate unwanted side effects,
mainly sedation
• Work peripherally to block the actions of histamine;
thus, fewer CNS side effects
• Longer duration of action (increases compliance)
Examples: fexofenadine (Allegra)

loratadine (Claritin)

Nursing Implications: Antihistamines
• Gather data about the condition or allergic reaction
that required treatment; also, assess for drug
allergies.
• Contraindicated in the presence of acute asthma
attacks and lower respiratory diseases.
• Use with caution in increased intraocular pressure,
cardiac or renal disease, hypertension, asthma,
COPD, peptic ulcer disease, BPH, or pregnancy.

• Instruct patients to report excessive

sedation, confusion, or hypotension.
• Avoid driving or operating heavy machinery,
and do not consume alcohol or other CNS
depressants.
• Do not take these medications with other
prescribed or OTC medications without
checking with prescriber.

• Best tolerated when taken with meals—

reduces GI upset.
• If dry mouth occurs, teach patient to perform
frequent mouth care, chew gum, or suck on
hard candy (preferably sugarless) to ease
discomfort.
• Monitor for intended therapeutic effects.

Decongestants

Nasal Congestion
• Excessive nasal secretions

• Inflamed and swollen nasal mucosa
• Primary causes:
– Allergies
– Upper respiratory infections (common cold)

Decongestants
Two main types are used:

• Adrenergics (largest group)
• Corticosteroids

Decongestants
Two dosage forms:

• Oral
• Inhaled/topically applied to the nasal membranes

Oral Decongestants
• Prolonged decongestant effects,

but delayed onset
• Effect less potent than topical
• No rebound congestion
• Exclusively adrenergics
• Examples: phenylephrine
pseudoephedrine (Sudafed)

Topical Nasal Decongestants
• Both adrenergics and steroids

• Prompt onset
• Potent
• Sustained use over several days causes
rebound congestion, making the condition
worse

Topical Nasal Decongestants
• Adrenergics:
ephedrine (Vicks) naphazoline (Privine)
oxymetazoline (Afrin) phenylephrine
(Neo Synephrine)
• Intranasal Steroids:
beclomethasone dipropionate
(Beconase, Vancenase)
flunisolide (Nasalide)

Nasal Decongestants:
Mechanism of Action
Site of action: blood vessels surrounding
nasal sinuses
• Adrenergics
– Constrict small blood vessels that supply
URI structures
– As a result, these tissues shrink and nasal
secretions in the swollen mucous membranes
are better able to drain
– Nasal stuffiness is relieved

Mechanism of Action
Site of action: blood vessels surrounding
nasal sinuses
• Nasal steroids
– Anti-inflammatory effect
– Work to turn off the immune system cells involved
in the inflammatory response
– Decreased inflammation results in decreased
congestion
– Nasal stuffiness is relieved
Nasal Decongestants: Drug Effects
• Shrink engorged nasal mucous membranes

• Relieve nasal stuffiness

Therapeutic Uses
Relief of nasal congestion associated with:
• Acute or chronic rhinitis
• Common cold
• Sinusitis
• Hay fever
• Other allergies
May also be used to reduce swelling of the nasal passage and
facilitate visualization of the nasal/pharyngeal membranes
before surgery or diagnostic procedures.

Nasal Decongestants: Side Effects
Adrenergics Steroids
nervousness local mucosal dryness
and irritation
insomnia
palpitations
tremors
(systemic effects due to adrenergic stimulation of
the heart, blood vessels, and CNS)

Nursing Implications:
Nasal Decongestants
• Decongestants may cause hypertension,
palpitations, and CNS stimulation—avoid in
patients with these conditions.
• Assess for drug allergies.

Nursing Implications: Decongestants
• Patients should avoid caffeine and caffeine-

containing products.
• Report a fever, cough, or other symptoms
lasting longer than a week.

Antitussives

Cough Physiology
Respiratory secretions and foreign objects are

naturally removed by the
• cough reflex
– Induces coughing and expectoration
– Initiated by irritation of sensory receptors in the
respiratory tract

Two Basic Types of Cough
• Productive Cough
– Congested, removes excessive secretions
• Nonproductive Cough
– Dry cough

Coughing
Most of the time, coughing is beneficial

• Removes excessive secretions
• Removes potentially harmful foreign substances
In some situations, coughing can be harmful,

such as after hernia repair surgery

Antitussives
Drugs used to stop or reduce coughing

• Opioid and nonopioid
(narcotic and non-narcotic)
Used only for NONPRODUCTIVE coughs!

Antitussives: Mechanism of Action
Opioid
• Suppress the cough reflex by direct action on the
cough center in the medulla.
Examples: codeine (Robitussin A-C, Dimetane-DC)
hydrocodone

Antitussives: Mechanism of Action
Nonopioid
• Suppress the cough reflex by numbing the stretch
receptors in the respiratory tract and preventing the
cough reflex from being stimulated.
Examples: benzonatate (Tessalon)
dextromethorphan (Vicks Formula 44,
Robitussin-DM)

Antitussives: Therapeutic Uses
• Used to stop the cough reflex when the

cough is nonproductive and/or harmful

Antitussives: Side Effects
Benzonatate
• Dizziness, headache, sedation
Dextromethorphan
• Dizziness, drowsiness, nausea
Opioids
• Sedation, nausea, vomiting, lightheadedness,
constipation

Antitussive Agents
• Perform respiratory and cough assessment,
and assess for allergies.
• Instruct patients to avoid driving or operating
heavy equipment due to possible sedation,
drowsiness, or dizziness.
• If taking chewable tablets or lozenges,
do not drink liquids for 30 to 35 minutes
afterward.

Antitussive Agents
• Report any of the following symptoms to the
caregiver:
– Cough that lasts more than a week
– A persistent headache
– Fever
– Rash
• Antitussive agents are for NONPRODUCTIVE

coughs.

Expectorants

Expectorants
• Drugs that aid in the expectoration
(removal) of mucus
• Reduce the viscosity of secretions
• Disintegrate and thin secretions

Expectorants: Mechanisms of Action
• Direct stimulation
or
• Reflex stimulation
Final result: thinner mucus that is easier to remove

Expectorants: Mechanism of Action
Direct stimulation:
• The secretory glands are stimulated directly to
increase their production of respiratory tract fluids.
Examples: terpin hydrate, iodine-containing
products such as iodinated glycerol and
potassium iodide (direct and indirect
stimulation)

Expectorants: Mechanism of Action
Reflex stimulation:
• Agent causes irritation of the GI tract.
• Loosening and thinning of respiratory tract
secretions occur in response to this irritation.
Examples: guaifenesin, syrup of ipecac

Expectorants: Drug Effects
• By loosening and thinning sputum and

bronchial secretions, the tendency to cough
is indirectly diminished.

Expectorants: Therapeutic Uses
Used for the relief of nonproductive coughs

associated with:
Common cold Pertussis
Bronchitis Influenza
Laryngitis Measles
Pharyngitis
Coughs caused by chronic paranasal sinusitis

Expectorants: Common Side Effects
guaifenesin terpin hydrate

Nausea, vomiting Gastric upset
Gastric irritation (Elixir has high alcohol
content)

Nursing Implications: Expectorants
• Expectorants should be used with caution in
the elderly, or those with asthma or
respiratory insufficiency.
• Patients taking expectorants should receive
more fluids, if permitted, to help loosen and
liquefy secretions.
• Report a fever, cough, or other symptoms
lasting longer than a week.

Drugs Affecting The Respiratory System

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Drugs Affecting the

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Most caused by viral infection

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Virus invades tissues (mucosa) of upper

• Irritation of nasal mucosa often triggers the

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Involves combined use of antihistamines,

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Upper Respiratory Tract

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Difficult to identify whether cause is viral or

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Drugs that directly compete with histamine

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

H1 antagonists are commonly referred

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

BLOCK action of histamine at the receptor sites

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• The binding of H1 blockers to the histamine

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• More effective in preventing the actions of

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Cardiovascular (small blood vessels)

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Smooth Muscle (on exocrine glands)

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Seasonal or perennial allergic rhinitis

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Also used to relieve symptoms associated

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Examples: fexofenadine (Allegra)

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Instruct patients to report excessive

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Best tolerated when taken with meals—

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Excessive nasal secretions

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Two main types are used:

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Two dosage forms:

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Prolonged decongestant effects,

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Both adrenergics and steroids

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

• Shrink engorged nasal mucous membranes

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.