Obat-obat untuk Saluran Pernapasan by leader6

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									Drugs affecting the Respiratory
           Systems


     Kuntarti, SKp, MBiomed
Anatomy & Physiology of
respiratory
1. The Upper respiratory tract
    nares, nasal cavity, pharynx,& larynx

2. The Lower respiratory tract
     trachea, bronchi, bronchioles, alveoli,
   & alveolar-capillary membrane
Ventilation & Respiration
   Ventilation
     is the movement of air from the
    atmosphere through the upper & lower
    airways to the alveoli
   Respiration
     the process whereby gas exchange
    occurs at the alveolar-capillary membrane
Phases of respiration
1.   Ventilation
      in which oxygen passes through the airways
2.   Perfusion
      in which blood from the pulmonary circulation is
     adequate at the alveolar-capillary bed
3.   Diffusion of gases
      in which oxygen passes into the capillary bed to be
     circulated and carbon dioxide leaves the capillary bed &
     diffuses into the alveoli for ventilatory excretion
 Lung compliance
1.   Connective tissue (collagen & elastin)
2.   Surface tension in the alveoli (by surfactant)

Control of respiration
    Chemoreceptors  changes of concentration of O2,
     CO2, H+
     *The central chemoreceptors: in the medulla near the
       respiratory center & cerebrospinal fluid (by:  CO2 &  pH)
     * Peripheral chemoreceptors: in the carotid & aortic bodies (by:
       changes of oxygen levels)
    Bronchial smooth muscle
   Contraction  constricts the airway

    * The vagus nerve (parasympathetic nervous
      system)  acetylcholine  bronchoconstriction

    * The sympathetic nervous system  epinephrine
       bronchodilatation
Common manifestations of
respiratory disease
   Sneeze
    - caused by a foreign body or irritant; inflammation
    - the early stages of a ‘cold’
    - requires no medication; a steroidal nasal spray for
       prophylactic
    - Sodium cromoglycate for prophylactically in the control
       of allergic rhinitis by topical inhalation (Hopkins, 1992)
   Sputum
    - purulent (by infection); frothy (by pulmonary edema);
      bloodstained (by haemoptysis); tenacious (by cystic
      fibrosis or mucous plugging)
    - Expectorants to liquefy mucus
Common manifestations of
respiratory disease
   Noisy breathing
    - Stridor is a rasping sound heard predominantly in
      inspiration
    - a cough that is caused by inflammation of the mucosa of
      the larynx, trachea, & bronchi, with narrowing of the
      subglottic area (by virus)
    - Medication: moist inhalations, nebulized steroids &
      adrenalin
Drugs affecting the Respiratory
Systems
   Drugs for asthma
    1. anti-inflammatory agents
    2. bronchodilators
   Drugs for rhinitis, cough, & colds
    1. nasal decongestans
    2. antihistamines
    3. anti-inflammatory agents
    4. antitussives
    5. Expectorants & mucolytics
Asthma
   common in children & adults
   characteristic signs: breathlessness,
    tightness in chest, wheezing, dyspnea, &
    cough
   chronic inflammatory disorder of the
    airway  a reaction to allergens
   symptoms of asthma: combination of
    inflammation & bronchoconstriction
Drugs for asthma
2 main pharmacologic class:
1. Anti-inflammatory agents: glucocorticoids &
   cromolyn
2. Bronchodilators: beta2 agonists


   most antiasthmatic drugs can be administered by
    inhalation, caused:
    - therapeutic effects are enhanced (by delivering drugs directly
    to their site of action)
    - systemic effects are minimized
    - relief of acute attacks is rapid
     Bronchodilator & antiasthma
   Sympathomimetics/Beta2-Adrenergic agonist
    - Examples: epinephrine, isoproterenol, isoetharine,
      albuterol, terbutaline, ephedrine
    - Use/ mechanism of action: treat asthma, bronchitis,
      & emphysema by stimulating beta2 receptors in bronchial
      smooth muscle to produce bronchodilatation, & thereby
      relieve bronchospasm
    - Adverse effect:
     CNS: restlessness, anxiety, dizziness,headache,
     insomnia; Cardiovascular: palpitations, cardiac
     arrhythmias, tachycardia, hypertension, cerebrovascular
     accidents, angina; GI: nausea, severe vomiting, diarrhea
Sympathomimetics

   Adverse effect:
     Skin: local necrosis & tissue sloughing from
     extravasated intravenous catecholamines
   Contraindication:cardiovascular diseases,
    phenochromacytoma, hypertension
   Precaution: hyperthyroidism, diabetes, & pregnancy
Glucocorticoids (steroid)
   Examples: dexamethasone, betamethasone, prednison
   Use/mechanism of action: steroids reduce symptoms of
    asthma by suppressing inflammation (decreased synthesis
    & release of inflammatory mediators; decreased
    infiltration & activity of inflammatory cells; decreased
    edema of the airway mucosa)
   Adverse effect: inhalation oropharingeal candidiasis &
    dysphonia (hoarseness & speaking difficulty); oral (in
    prolonged therapy adrenal suppression, osteoporosis,
    hyperglycemia, peptic ulcer disease, & suppression of
    growth (in young patients)
Glucocorticoid
   Contraindication: systemic fungal
    infections; individuals receiving live-virus
    vaccines
   Cautions: pediatric, pregnant & breast
    feeding woman
Cromolyn/ Mast cell stabilizers
   Examples: Cromolyn, Nedocromyl
   Use/ mechanism of action: Cromolyn suppresses
    inflamation by stabilizing the cytoplasmic
    membrane of mast cells, thereby preventing
    release of histamine & other mediators. Cromolyn
    inhibits eosinophils, macrophages & other
    inflammatory cells
   Adverse effects: cromolyn is the safest of all
    antiasthmatic medications, the most common
    reactions are wheezing, coughing & unpleasent
    taste
Methylxanthines
   Examples: Theophylline, aminophylline,
    dyphylline
   Use/ mechanism of action: theophylline produces
    bronchodilatation by relaxing smooth muscle of
    the bronchi, the most probable mechanism is
    blockade of receptors for adenosine.
   Adverse effects: theophylline has a narrow
    therapeutic range, & hence dosage must be
    carefully controlled; at plasma levels > 20μg/ml :
    nausea, vomiting, diarrhea, insomnia, restlesness,
    dysrhythmia & convulsion
Anticholinergic/ muscarinic antagonist
   Examples: atropine, ipatropium bromide
    (atrovent)
   Use/ mechanism of action: by blocking
    muscarinic cholinergic receptors in bronchi, &
    thereby promotes bronchodilatation
   Adverse effects: dryness of oropharynx, cough
Drugs for rhinitis
   Rhinitis: an inflammation of the nasal
    mucous membranes
   Symptoms: sneezing, rhinorrhea, nasal
    itching, & nasal congestion
   Allergic & non-allergic
   Drugs: (1) nasal decongestants (2)
    antihistamines (3) intranasal anti-
    inflammatory
Nasal decongestants
   Examples: phenylephrine, phenylpropanilamine (ppa)
   Use/ mechanism of action: by stimulating alpha1-
    adrenergic receptors on smooth muscle of nasal
    blood vessels  vasocontriction  shrinkage of
    swollen membranes nasal drainage; topical
    administration more rapid & intense than oral
    administration
   Adverse effects: rebound congestion; CNS
    stimulation; cardiovascular effects widespread
    casoconstriction
   Contraindication & caution: hypertension & CAD
Antihistamines (H1-receptor antagonist)
   Examples: diphenhydramine, chlorpheniramine,
    promethazine, azatadine (1st generation), terfenadine,
    astemizole, loratadine (2nd generation)
   Use/ mechanism of actions: these agents can relieve
    sneezing, rhinorrhea, & nasal itching by blocking H1
    receptor & thereby preventing the actions histamines
    at these sites
   Adverse effects: sedation (1st generation), cardiac
    dysrytmia, dizzines, nausea, vomiting,constipation,
    dry mouth
Drugs for cough & cold
   Cough: a complex reflex involving the
    central & pheripheral nerve systems &
    muscles of respiration can be initiated by
    irritation of the bronchial mucosa
   (+): remove foreign matter & excess
    secretions from the bronchial tree
   (-): deprive us of comfort & sleep
   Common cold: an acute upper respiratory
    infection of viral origin
   Symptoms: rhinorrhea, sneezing, cough,
    sore throat, headache, malaise,& myalgia
   Combination cold remedias, 2 or more of:
    1. nasal decongestants
    2. antitussives
    3. analgesic
    4. antihistamines
    5. caffeine
Antitussive agents
   Examples: opioid  codeine, hydrocodone; non-
    opioid dextromethorpan hydrobromide (DMP)
   Use/ mechanism of action: suppress coughing by
    altering response threshold of cough center in the
    medulla or peripherally by inhibiting pulmonary
    stretch, thus decreasing impulses to the cough
    center
Antitussive agents
   Adverse effects:
    - Codeine: impaired alertness or coordination,
    hypersensitivity, dependence; toxic reactions: euphoria,
    hyperactivity, nystagmus, uncoordinated movements,
    stupor, shallow breathing
    - DMP: drowsiness & GI upset; toxic reaction: miosis,
    bradycardia, tachycardia, hypotension, narcosis, seizures,
    circulatory collapse
   Contraindication: pregnancy, lactation, known
    hypersensitivity
Antitussive agents
   Precautions: benign prostatic hypertrophy, debilitation,
    thoracotomy, laparotomy, history of drug abuse
   Drug interactions:
    - DMP and MAO (monoamine oxidase) inhibitors:
      excitation, hyperpyrexia
    - narcotic/opioid antitussive with MAO inhibitors,
      alcohol, & other CNS depressants: potentiation of CNS
      depressive effects
Expectorants agents
   Examples: ammonium chloride, guaifenesin/glyceryl
    guaiacolate (GG)
   Use/ mechanism of action:facilitate expulsion of
    mucus by reducing adhesiveness and surface tension of
    mucus
   Precaution:liver and renal insufficiency
   Adverse effects:
    - GG: drowsiness, nausea, vomiting
Mucolytic agents
   Examples: bromhexin, ambroxol, acetilcistein,
    hypertonic saline
   Use/ mechanism of action: enhance mucolysis by
  altering molecular composition of mucus, reducing
  viscosity; ambroxol: stimulate surfactant production of
  premature infant with respiratory distress syndromes
 Precaution: gastric ulcer
 Adverse effects:
  - bromhexin: nausea,  serum transaminase level
  - acetilcistein: bronchial spasm, nausea, vomiting,
    stomatitis, haemoptysis
     Nursing diagnosis
1.    Ineffective airway clearance related to
      mucus accumulation manifested by cough &
      ronchi
2.    Risk for infection related to build up of
      respiratory secretions
3.    Risk for injury related to CNS depression
Nursing implementation
   Administration procedures
    * Increase fluid intake of client taking expectorant
   Daily monitoring & measurements
    * Monitor client taking codeine for signs of respiratory depression
   Client teaching
    1. Explain to client the importance of increasing fluid intake when
        taking expectorant
    2. Encourage patient who is confined to bed and taking expectorant to
        turn, breathe deeply, & cough every 2 hours
    3. Warn client taking a narcotic antitussive not to drink alcohol
    4. Caution client that prolonged use of codeine may cause
        dependence
    5. Show client how to use and clean nebulizer for acetylcystein
       administration
Nursing evaluation
Client shows:
 Absence of coughing.
 Improved ability to cough up mucus.
 No signs or symptoms of infection
    (Cardinal signs).
 No signs of excessive CNS depression.

								
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