Bronchodilators inhaled

Moderate persistent Daily Daily use of Pj-agonists Exacerbations may affect activity Exacerbations a twice a week 60-80% predicted PEF variability > 30% Step 2 with medium dose of inhaled corticosteroid If needed, ADD a long-acting bronchodilator (inhaled sal-meterol, oral Pj-agonist, or theophylline)... 

Ifthepatient is using a bronchodilator inhaler concomitantly with a steroid inhaler, use the bronchodilator several minutes before using the corticosteroid to help the steroid penetrate into the bronchial tree... 

Sulfites and bisulfites have been used extensively as preservatives in the food industry and also in drugs and bronchodilator inhalant solutions (1,2) as preservatives. Sodium metabisulfite is used commonly as an antioxidant in foods and drugs. As an additive in various pharmaceutical products, metabisulfite can cause unpleasant adverse reactions. 

If more than one type of inhaled medication is taken it is important to take them in the correct order. Bronchodilating inhalers are used first to help open the airways. These are followed by corticosteroid inhalers. This ensures that the airways are open when the corticosteroid is administered, allowing as much of the dose as possible to be absorbed. 

Demonstrate how the patient or family members are to administer medication. For example, show the proper injection techniques if the patient requires insulin injections or the correct use of bronchodilator inhalers for asthma. Don t assume that they can administer the medication after seeing you do it. Make sure to have the patient and family members show you how they plan to give the medication. This is especially critical when medication is given using a syringe, topical dmgs, and inhalers. The patient and the caregiver must have visual acuity, manual dexterity, and the mental capacity to prepare and administer medication. 

Chen CY, Bonham AC, Plopper CG, Joad JP (2003) Neuroplasticity in nucleus tractus sohtarius neurons after episodic ozone exposure in infant primates. J Appl Physiol 94 819-827 Chong CF, Chen CC, Ma HP, Wu YC, Chen YC, Wang TL (2005) Comparison of lidocaine and bronchodilator inhalation treatments for cough suppression in patients with chronic obstructive pulmonary disease, Emerg Med J 22 429 32... 

Simmons M, Nides MA, Rand CS, Wise RA, Tashkin DP. Trends in compliance with bronchodilator inhaler use between follow up visits in a clinical trial. Chest 1996 109(4) 963-968. 

At this writing anticholinergic agents are not widely used for the symptomatic treatment of asthma, although compounds such as atropine [51 -55-8] C17H23NO3, (18) have been used for centuries (111). Inhalation of the smoke produced by burning herbal mixtures, such as Datura Stramonium provided bronchodilation and rehef from some of the symptoms of asthma. The major active component in these preparations was atropine or other closely related alkaloids (qv). 

The action of epinephrine and related agents forms the basis of therapeutic control of smooth muscle contraction. Breathing disorders, including asthma and various allergies, can result from excessive contraction of bronchial smooth muscle tissue. Treatment with epinephrine, whether by tablets or aerosol inhalation, inhibits MLCK and relaxes bronchial muscle tissue. More specific bronchodilators, such as albuterol (see figure), act more selec-... 

Asthma attacks more than twice a week FEV1 60-80% daily use of bronchodilators. Rapid-acting inhaled p2-agonist Inhaled glucocorticoid... 

Inhaled steroids (commonly used are beclomethasone, budesonide, triamcinolone, fluticasone, flunisolide) appear to attenuate the inflammatory response, to reduce bronchial hyperreactivity, to decrease exacerbations and to improve health status they may also reduce the risk of myocar dial infar ction, but they do not modify the longterm decline in lung function. Whether- steroids affect mortality remains unclear. Many patients appear to be resistant to steroids and large, long-term trials have shown only limited effectiveness of inhaled corticosteroid ther apy. Certainly, the benefit from steroids is smaller in COPD than in asthma. Topical side-effects of inhaled steroids are oropharyngeal candidiasis and hoarse voice. At the normal doses systemic side-effects of inhaled steroids have not been firmly established. The current recommendation is that the addition of inhaled gluco-coiticosteroids to bronchodilator treatment is appropriate for patients with severe to veiy sever e COPD. 

Administration of a sympathomimetic bronchodilator may result in restlessness, anxiety, increase in blood pressure, palpitations, cardiac arrhythmias, and insomnia When these dragp are used by inhalation, excessive use (eg, over the recommended times) may result in paradoxical bronchospasm. 

Q Risk for Impaired Oral Mucous Membrane related to adverse reactions ot the bronchodilating and antiasthma inhalants... 

Salmeterol is a long-acting inhaled bronchodilator and is not used to treat acute asthma symptoms. It does not replace the fast-acting inhalers for sudden symptoms. Salmeterol should not be used more frequently than twice daily (morning and evening). 

PATIENTS TAKING CORTICOSTEROID INHALANTS If the patient is receiving a sympathomimetic bronchodilator by inhalation and a corticosteroid such as triamcinolone by inhalation, die nurse administers the bronchodilator first, waits several minutes, then administers die corticosteroid inhalant. When administering two inhalations of die same drug, it is advisable to wait at least 1 minute between puffs. 

Educating the Patient and Family If die patient is to use an aerosol inhalator for administration of die bronchodilator, die nurse provides a... 

Salmeterol is not meant to relieve acute asthmatic symptoms. Notify the physician immediately if salmeterol becomes less effective for symptom relief, if more inhalations than usual are needed, or if more than the maximum number of inhalations of shortacting bronchodilators are needed. 

In light of the information presented, it appears that liposomes have much to offer as an improved delivery system for inhaled bronchodilators as they can provide sustained release, solubilization, stability, and safety in an inhalable formulation. 

In cases of severe acute asthmatic attacks, bronchodilators and steroids for direct dehveiy to the lungs may be needed in large doses. This is achieved by direct inhalation via a nebulizer device this converts a liquid into a mist or fine spray. The dmg is diluted in small volumes of Water for Injections BP before loading into the reservoir of the machine. This vehicle must be sterile and preservative-fiee and is therefore prepared as a terminally sterilized unit dose in polyethylene nebules. 

Add standing treatment with one or more long-acting bronchodilators (i.e., tiotropium, salmeterol, and formoterol) ° Add inhaled corticosteroid therapy if repeat exacerbations... 

A greater than or equal to 12% (at least 200 mL) improvement in FEV after an inhaled bronchodilator demonstrates a reversible obstruction. A 2- to 3-week course of oral corticosteroids may be necessary to demonstrate reversibility in airway obstruction. 

Short-acting bronchodilator 2-4 puffs short-acting inhaled p2-agonist as needed for symptoms... 

Salmeterol and formoterol are long-acting inhaled p2-agonists that provide up to 12 hours of bronchodilation after a single dose. Both agents are approved for the chronic prevention of... 

Theophylline is also considered an alternative to inhaled corticosteroids for the treatment of mild persistent asthma however, limited efficacy compared to inhaled corticosteroids, a narrow therapeutic index with life-threatening toxicity, and multiple clinically important drug interactions have severely limited its use. Theophylline causes bronchodilation through inhibition of phosphodiesterase and antagonism of adenosine and appears to have anti-inflammatory and immunomodulatory properties as well.36... 

The optimal treatment of acute severe asthma depends on the severity of the exacerbation (Figs. 11-2 and 11-3). The patient s condition usually deteriorates over several hours, days, or weeks however, rapid deterioration can occur in some patients.3 Gradual deterioration may indicate failure of long-term controller therapy. Patients with rapid deterioration usually respond well to bronchodilator therapy.40 Severity at the time of the evaluation can be estimated by signs and symptoms, but patient response 30 minutes after inhalation of a bronchodilator is the best predictor of outcome.12... 

Theophylline is not recommended for treatment of acute asthma.2 It provides no additional benefit when optimal inhaled bronchodilators are used and increases the risk of adverse events. Similarly, although magnesium has bron-chodilator activity, it offers no significant benefits when optimal bronchodilator therapy is used.12,40... 

I Mild Short-acting inhaled bronchodilator when... 

P2-Agonists cause airway smooth muscle relaxation by stimulating adenyl cyclase to increase the formation of cyclic adenosine monophosphate (cAMP). Other non-bronchodilator effects have been observed, such as improvement in mucociliary transport, but their significance is uncertain.11 P2-Agonists are available in inhalation, oral, and parenteral dosage forms the inhalation route is preferred because of fewer adverse effects. 

Theophylline is a non-specific phosphodiesterase inhibitor that increases intracellular cAMP within airway smooth muscle resulting in bronchodilation. It has a modest bronchodila-tor effect in patients with COPD, and its use is limited due to a narrow therapeutic index, multiple drug interactions, and adverse effects. Theophylline should be reserved for patients who cannot use inhaled medications or who remain symptomatic despite appropriate use of inhaled bronchodilators. 

Leukotriene modifiers (e.g., zafirlukast and montelukast) have not been adequately evaluated in COPD patients and are not recommended for routine use. Small, short-term studies showed improvement in pulmonary function, dyspnea, and quality of life when leukotriene modifiers were added on to inhaled bronchodilator therapy.27,28 Additional long-term studies are needed to clarify their role. 

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