Respiratory system

The main function of the respiratory system is to:

 Deliver oxygen
 Remove carbon dioxide from the cells of the body 

To perform this simple task requires a very intricate system of tissues, muscles, and organs
called the respiratory system. 

It consists of two divisions or tracts: 

1. The upper respiratory tracts

2. The lower respiratory tracts

The upper respiratory tract (URT) is: 

 Composed of the structures that are located outside of the chest cavity or thorax.

The lower respiratory tract (LRT) is:

 Located almost entirely within the thorax 

Composed of the trachea

 All segments of the bronchial tree

 The lungs
 Alveoli

The respiratory system is subject to many disorders that interfere with respiration and
other lungs function including: 

 Respiratory tract infection,

 Allergic and inflammatory disorders,
 Conditions that obstruct airflow (e.g. Asthma, Chronic obstruction pulmonary diseases
(COPD)

Definitions

 Antihistamines Substances
capable of reducing the
Respiratory system

physiologic and pharmacologic

effects of histamine.
1. Antihistamines- Substances capable of reducing the physiologic and pharmacologic
effects of histamine.
2. Decongestants- Drugs that reduce congestion or swelling, especially of the upper or
lower respiratory tract.
3. Antitussive- A drug that reduces coughing, often by inhibiting neural activity in the
cough center of the central nervous system.
4. Expectorants- Drugs that increase the flow of fluid in the respiratory tract, usually by
reducing the viscosity of secretions, and facilitate their removal by coughing.
5. Bronchodilators- Medications that improve airflow by relaxing bronchial smooth
muscle cells (e.g., Xanthine, adrenergic agonists).
6. Lower respiratory tract (LRT) The division of the respiratory system composed of
organs located almost entirely within the chest.
7. Upper respiratory tract (URT) The division of the respiratory system composed of
organs located outside the chest cavity (thorax). 

Note: Antihistamines, Decongestants, Antitussive, Expectorants are only use to treat

symptoms of URI they cannot eliminate the causative pathogen.

 Bronchodilators are use two treat diseases of the LRT (e.g. asthma, COPD)

Drugs affecting the respiratory system

(Antihistamines, Decongestants, Antitussive, Expectorants)

Most colds are cause my viral infection

 Rhinovirus virus
 Influenza virus

These viruses invade the mucosa of the upper respiratory tract causing an URI.

Antihistamines

 Inhibit the action of histamine in the body

 Histamine has many functions.
 Involved in nerve impulse transmission in the CNS
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 Dilation of capillaries
 Contraction of smooth muscle
 Stimulation of gastric secretion
 Acceleration of the heart rate
 Produces inflammatory response and allergic reactions

There are two types of cellular receptors for histamine

 Histamine 1 (H1) - receptors mediate smooth muscle contraction and dilation of

capillaries
 Histamine 2 (H2) - receptors mediate acceleration of the heart rate and gastric acid
secretion. 

Histamine 1 (H1)

 Histamine receptor belonging to the family of Rhodopsin-like G-protein-coupled

receptors
 Activated by the biogenic amine histamine
 Expressed throughout the body in smooth muscles
 On vascular endothelial cells 
 The heart
 Antihistamines, which act on this receptor, are used as anti-allergy drugs.

Histamine 2 (H2)

 H2 receptors are positively coupled to adenylate cyclase via Gs

 Potent stimulant of cAMP production which leads to activation of Protein Kinase A
 The drug betazole is an example of a Histamine H2 receptor agonist

Antihistamines

 The release of excessive amounts of histamine can lead to anaphylaxis and severe allergic
symptoms and may result in any or all of the following physiologic changes:
 Constriction of smooth muscle 
 Increase in body secretions
 Vasodilatation and increased capillary permeability
 Antihistamines compete with histamine for specific receptor site and are also called
histamine antagonists
 Antihistamines that compete with histamine for the H2 receptors are called H2
antagonists or H2 blockers 
 H1 antagonists (also called H1 blockers); are drugs commonly known as antihistamines
 Major inflammatory mediator in many allergic disorders.
Respiratory system

Drugs

 Allegra
 Benadryl
 Claratin

Mechanism of action and drug effects

 During allergic reactions, histamine and other substances are released from mast cells,
basophils, and other cells in response to antigens circulating in the blood.
 Histamine molecules then bind to and activate other cells producing the characteristic
allergic signs and symptoms.
 Histamine causes pruritus by stimulating nerve endings. 
 Antihistamines can prevent or alleviate this itching.
 Work by blocking the histamine receptors on the surfaces of basophils and mast cells,
preventing the release and actions of histamine. 

Indications

 Management of nasal allergies,

 Seasonal or perennial allergic rhinitis (e.g., hay fever)
 Useful in the treatment of allergic reactions, motion sickness, Parkinson’s disease, and
vertigo

Contraindications

 Contraindicated in cases of known drug allergy. 

 Not to be used as the sole drug therapy during acute asthmatic attacks.

Adverse effects

 Drowsiness is usually the chief complaint of people who take Antihistamines

 Anticholinergic (drying) effects of antihistamines can cause adverse effects such as: 
 Dry mouth
 Changes in vision
 Difficulty urinating
 Constipation

Decongestants

Nasal decongestants

 Nasal congestion is due to excessive nasal secretions and inflamed and swollen nasal
mucosa.
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 The primary causes of nasal congestion are allergies and URIs, especially the
common cold.
 There are three separate groups of nasal decongestants:
 Adrenergic (sympathomimetic)
 Anticholinergics (para-sympatholytic)
 Corticosteroids (intranasal steroids)

Decongestants

 Decongestants can be taken orally to produce

a systemic effect, can be inhaled, or can be
administered topically to the nose
 Decongestants can be taken orally to produce a systemic effect, can be inhaled, or
administered topically on the nose
 Commonly used intranasal steroids include the following:
 Beclomethasone dipropionate (Beconase)
 Budesonide (Rhinocort)
 Flunisolide (Nasalide)
 Fluticasone (Flonase)
 Triamcinolone (Nasacort)
 Ciclesonide (Omnaris)
 The only intranasal anticholinergic drug in use is ipratropium nasal spray (Atrovent).

Mechanism of action

 Used for their ability to:

 shrink engorged nasal mucous membranes 
 Relieve nasal stuffiness
 They constrict the small arterioles that supply the structures of the upper respiratory tract
 Blood vessels constrict when stimulated by alpha-adrenergic drugs
 Nasal secretions are drain either internally or externally
 Sympathomimetic drugs stimulate the sympathetic nervous system and has the same
effect
 Nasal steroids causes inflammation to antigen
 The body responds to these antigens by producing inflammation
 Steroids exert their anti-inflammatory effect by causing these cells to be turned off or
rendered unresponsive.
 Commonly used with antihistamines
Respiratory system

Indications

Nasal decongestants reduce the nasal congestion associated with:

 Acute or chronic rhinitis

 The common cold
 Sinusitis
 Hay fever or other allergies
 Reduce swelling of nasal passage
 Allergies

Contraindications

 Contradiction to the use of decongestants include drug allergy:

 Adrenergic drugs are contradicted in:
 Narrow-angle glaucoma
 Uncontrolled heart disease
 Hypertension
 Diabetes
 Hyperthyroidism
 Prostatis

Adverse effects

 Possible adverse effects include:

 Nervousness
 Insomnia
 Palpitation
 Tremor
 Excessive dosage of this medication are likely to cause systemic effects elsewhere in the
body

Interactions

 Systemic sympathomimetic drugs and sympathomimetic nasal decongestants are likely to

cause drug toxicity when given together.
Respiratory system

Antitussive

 May enhance patient comfort and reduce respiratory distress.

 Two categories of antitussive drugs: 
 Opioid (hydrocodone, codeine)
 Non-opioid( acetaminophen/doxylamine/dextromethorphan,
 Aspirin/diphenhydramine, Alka Seltzer Plus Night and Cold Effervescent)

Opioids & Non-opioids

 All have antitussive effects the CNS but only 2 are used as antitussives. They are:
 Hydrocodone 
 Codeine 
 Non opioid
 Less effective than opioid drugs 
 Normally use with a combination of other over the counter (OTC) cold
medications
 Dextromethorphan - most popular non-opioid antitussive available OTC.

Mechanism of action & Drug effects

Respiratory system

 The opioid antitussives codeine and hydrocodone suppress the cough reflex through
direct action on the cough center in the CNS
 Non-opioid cough suppressant works in the same way
 Non opioids suppresses the cough reflex by anesthetizing
 Opioid antitussives also provide analgesia and have a drying effect on the mucosa of the
respiratory tract.

Indications

 Antitussives are used primarily to stop the cough reflex when the cough is non-
productive and/or harmful.

Contraindications

 Drug allergy
 Relative contraindications include:
 Opioid dependency
 High risk for respiratory depression

Adverse effects

 Benzonatate: 
 Dizziness, headache, sedation,
  Nausea, constipation,
 Pruritus, and nasal congestion
 Codeine and hydrocodone: 
 Sedation, nausea, vomiting,
 Light headedness, and constipation, respiratory depression
 Dextromethorphan:
 Dizziness, drowsiness, and nausea
 Diphenhydramine: 
 Sedation, dry mouth
 Other anticholinergic effects

Interaction

 Few drug interactions occur with benzonatate.

 Opioid antitussives may potentiate the effects of:
 Other opioids
 General anesthetics
 Tranquilizers sedatives and hypnotics
 Tricyclic antidepressants
 Alcohol
Respiratory system

 Other CNS depressants

  

Type of Drug Drug Dosage Range Availability

Non-opioid Benzonatate Adult & pediatric Oral form as a 100-
Antitussive (Tessalon Perles) older than 10 yr. and 200-mg capsules

PO: 100-200 mg t.i.d

Non-opioids Dextromethorphan Adult & pediatric Lozenges, solution,
Antitussive older than 12 yr. Liquid filled capsules,
Granules, tablets
PO: 10-30mg q4-8hr, (chewable, extended-
max 120 mg/24 hr. release, and film
coated), and extended
Pediatric 6-12 yr. release suspension

PO: 5-10mg q4h or

15mg q6-8h, max
60mg/24hr.

Pediatric 2-6 yr.

PO: 2.5-7.5mg q4-8h,

max 30mg/24h

Opioid Non-opioid

Pharmacokinetics: Pharmacokinetics:

Route: Per oral (PO) Route: PO

Onset of Action: 15-30 min Onset of Action: 15-30 min

Peak Plasma Concentration: 34-45 min Peak plasma concentration: 2.5 hr.

Elimination Half-life: 2.5-4 hr. Elimination Half-life: Unknown

Duration of Action: 4-6 Duration of Action: 3-6 hrs.

Expectorants
Respiratory system

 Increase the bronchial secretion and enhance the expulsion of mucus by air passages of
the lungs.
 The most common expectorant in OTC products is guaifenesin (Mucinex, Robitussin)
 Guaifenesin 
 Beneficial in the treatment of productive coughs because it thins mucus in
the respiratory tract that is difficult to cough up.

Mechanism of action & Drug effect

 Two different mechanisms of action, depending on the drug

 Reflex stimulation-loosening and thinning of respiratory tract secretion
 Direct stimulation of the secretory glands in the respiratory tract

Indications

 Expectorants are
 Used for the relief of productive cough 
 Used for the suppression of coughs caused by chronic paranasal sinusitis
 By loosening and thinning sputum and the bronchial secretions,
 May also indirectly diminish the tendency to cough.

Contraindications

 Guaifenesin is contraindicated if drug allergy is present.

Adverse Effects

 The adverse effects of expectorants are minimal. 

 Guaifenesin may cause nausea, vomiting, and gastric irritation

Interactions

 No known significant interactions involving guaifenesin.

Respiratory system

Treatment of diseases of the lower respiratory tract

Bronchodilators

 Relax the bronchial smooth muscles, which causes dilation of the bronchi and
bronchioles that are narrowed because of the disease process. 
 There are three classes of such drugs:
 Beta adrenergic agonists, 
 Anticholinergics, 
 Xanthine derivatives.

Beta adrenergic agonist

 A group of drugs commonly used during the acute phase of an asthmatic attack to quickly
reduce airway constriction and to restore airflow to normal. 
 Are agonists, or stimulators, of the adrenergic receptors in the sympathetic nervous
system.
Respiratory system

 Imitate the effects of norepinephrine on beta receptors aka also called sympathomimetic
bronchodilators.
 Categorized by their onset of action. 
 Short-acting beta agonist (SABA) are 

Mechanism of action & Drug effect

 Beta agonists dilate airways by stimulating the beta2- adrenergic receptors located
throughout the lungs
 Three subtypes of these drugs, based on their selectivity for beta 2 receptors:
 Nonselective adrenergic drugs, which stimulate the
 Beta, 
 Beta1 (cardiac), 
 Beta2 (respiratory) receptors. Example: epinephrine. 
 Nonselective beta-adrenergic drugs, which stimulate:
Respiratory system

 Beta 1 and beta 2 receptors. Example: Metaproterenol.

 Selective beta2 drugs, which primarily stimulate:
 Beta 2 receptors. Example: albuterol. 

Beta agonist bronchodilators

 Categorized according to their routes of administration as oral, injectable, or inhaled.

 Bronchioles are surrounded by smooth muscle.
 Smooth muscle contracts, the airways are narrowed and the amount of oxygen and carbon
dioxide exchanged is reduced. 
 Action of beta agonist bronchodilators begins at the specific receptor stimulated and ends
with the dilation of the airways. 
 Reactions must take place at the cellular level for this bronchodilation to occur. 
 Beta2-adrenergic receptor is stimulated by a beta agonist, adenylate cyclase is activated
and produces cyclic adenosine monophosphate (cAMP). 
 Adenylate cyclase is an enzyme needed to make cAMP. 
 Increased levels of cAMP cause bronchial smooth muscles to relax, which results in
bronchial dilation and increased airflow into and out of the lungs.
 Nonselective adrenergic agonist drugs such as epinephrine also stimulate alpha-
adrenergic receptors, causing constriction within the blood vessels
Respiratory system

 Vasoconstriction reduces the amount of edema or swelling in the mucous membranes

limiting the quantity of secretions normally produced 
 These drugs stimulate beta1 receptors, resulting in cardiovascular adverse effects such as:
 An increase in heart rate
 Force of contraction
 Blood pressure
 Central nervous system (CNS) effects such as nervousness and tremor
 Have more specific drug effects and cause less adverse effects
 Stimulating the beta2-adrenergic receptors of the bronchial and vascular smooth muscles
 Causes bronchodilation and may also have a dilating effect on the peripheral vasculature,
which results in a decrease in diastolic blood pressure.

Indications

 Primary therapeutic effect of the beta agonists is the prevention or relief of bronchospasm
related to bronchial asthma, bronchitis, and other pulmonary diseases
 Used for effects outside the respiratory system
 These drugs have the ability to stimulate both beta1- and alpha-adrenergic receptors, they
may be used to treat hypotension and shock.

Contraindications

 Include known drug allergy

 Uncontrolled hypertension or cardiac dysrhythmias 
 High risk of stroke (because of the vasoconstrictive drug action).

Adverse effects

 Mixed alpha/beta agonists produce the most adverse effects because they are nonselective
 Include insomnia, restlessness, anorexia, cardiac stimulation, hyperglycemia, tremor, and
vascular headache
 Limited to beta-adrenergic effects, including cardiac stimulation, tremor, anginal pain,
and vascular headache
 Beta2 drugs can cause both hypertension and hypotension, vascular headaches, and
tremor

Interactions

 Nonselective beta blockers are used with the beta agonist bronchodilators
 Set of beta agonists with monoamine oxidase inhibitors and other sympathomimetic is
best avoided because of the enhanced risk for hypertension
Respiratory system

 Diabetics may require an adjustment in the dosage of their hypoglycemic drugs,

especially patients receiving epinephrine, because of the increase in blood glucose levels
that can occur.

Anticholinergics

 There are two anticholinergic drugs used in the treatment of COPD and Asthma: 
 Ipratropium (Atrovent) 
 Tiotropium (Spiriva).

Xanthines derivatives

 Natural xanthine consists of the plant alkaloids caffeine, theobromine, and theophylline,
but only theophylline and caffeine are currently used clinically.

Non-bronchodilators

 Other drugs that are effective in suppressing the various underlying causes of some of the
respiratory illnesses
 These include:
 Leukotriene receptor antagonists (montelukast, zafirlukast, and zileuton) 
 Corticosteroids (beclomethasone, budesonide, dexamethasone, flunisolide,
fluticasone, ciclesonide, and triamcinolone)
 *Mast cell stabilizers (cromolyn and nedocromil)*
Respiratory system

Mechanism of action of Leukotrienes

 Leukotrienes are:
 Inflammatory molecules that are released by mast cells during an asthma
attack
 Primarily responsible for the bronchoconstriction
 Leukotriene receptor antagonists are among the most prescribed drugs for the
management of asthma
 Used both for treatment and prevention of acute asthmatic attacks

This class is subdivided into two:

 The first subclass of LTRAs 

 Acts by an indirect mechanism and inhibits the enzyme 5-lipoxygenase,
which is necessary for leukotriene synthesis. Zileuton 
 The second subclass of LTRAs 
 Acts more directly by binding to the D4 leukotriene receptor subtype in
respiratory tract tissues and organs.
 This class of drugs acts by:
 Binding to cysteinyl leukotriene (CysLT) receptors
 Blocking their activation and the subsequent inflammatory cascade
 Which cause the symptoms commonly associated with asthma and allergic rhinitis
 LTRAs prevent leukotrienes from attaching to receptors located on: 
 Circulating immune cells 
 Local immune cells within the lungs
 This alleviates asthma symptoms in the lungs by reducing inflammation. 
 They prevent smooth muscle contraction of the bronchial airways
 Decrease mucus secretion
 Reduce vascular permeability through their reduction of leukotriene synthesis

Adverse effects of Leukotriene

The most common reactions of leukotriene are:

 Upper respiratory infection

 Fever
 Headache
 Pharyngitis
 Cough
 Abdominal pain
 Diarrhea
Respiratory system

Mechanism of action for Corticosteroids

 Also known as glucocorticoids 

 Used to treat chronic asthma and act against inflammation
 Stabilize membranes of cells that normally release Broncho constricting substances 
 Restore or increase the responsiveness of bronchial smooth muscle to beta- adrenergic
receptor stimulation, 

Adverse effects of Corticosteroids

 Inhaled corticosteroids in the respiratory system include 

 Pharyngeal irritation
 Coughing
 Dry mouth
 Oral fungal infections

Mechanism of action for Mast Cell Stabilizers

 These drugs are rarely used. They include cromolyn and nedocromil
 Sometimes used for exercise-induced asthma.
 Found throughout the body
 Release substances that result in inflammation
 Prevent the release of the substances that cause inflammation
 May reduce asthma symptoms

Adverse effects of Mast Cell Stabilizers

Common side effects of this medicine include:

 Throat irritation and coughing.

 Nausea and vomiting.
 heartburn
 abdominal pain  

Monoclonal antibody anti-asthmatic

 This is the newest anti-asthmatic medication that is available

 Monoclonal antibody that selectively binds to the immunoglobulin IgE, which in turn
limits the release of mediators of the allergic response.

Nursing Process

Assessment
Respiratory system

 Physical assessment
 Psychosocial and emotional assessment
 History

Nursing diagnosis

 Impaired gas exchange related to pathophysiologic changes caused by respiratory disease

 Fatigue related to the disease process and lack of oxygen saturation
 Noncompliance with the medication regimen related to undesirable adverse effects of
drug therapy
 Ineffective Airway Clearance Evidences by:
 Difficulty breathing
 Changes in depth and rate of respiration 
 Use of respiratory accessory muscles
 Persistent ineffective cough with/without sputum production 
 Wheezing upon inspiration and expiration 
 Dyspnea, Coughing, Tachypnea 
 Prolonged expiration 
 Tachycardia
 Chest tightness 
 Suprasternal retraction 
 Restlessness 
 Anxiety Cyanosis 
 Loss of consciousness
 Related to:
 Increased production or retainment of pulmonary secretions 
 Bronchospasms 
 Decreased energy Fatigue
 Impaired Gas Exchange evidenced by:
 Wheezing upon inspiration and expiration
 Dyspnea, Tachypnea, coughing
 Sputum is yellow and sticky
 Prolonged expiration 
 Tachycardia
 Chest tightness
 Suprasternal retraction
 Restlessness
 Anxiety
 Cyanosis
 Altered loc
 Changes in ABGs
Respiratory system

 May be related to:

 Altered delivery of inspired O2 or air trapping

Planning goals

 Improved gas exchange due to improved disease process and symptomatology. 

 Improved energy and less fatigue.
 Remains compliant with the medication regimen and with the non-pharmacologic
therapies.

Outcome criteria

 Patient is able to describes measures to improve gas exchange such as:

 Use of deep breathing
  Use of medications as described
 How to avoid precipitating factors
 Patient shows evidence of improved oxygen levels with an SpO2 greater than or equal to
95% (depending on pathology).

Implementation

 Nursing interventions that apply to patients with respiratory disease processes (e.g.,
COPD, asthma, other upper and lower respiratory tract disorders) include:
 Patient education 
 And an emphasis on compliance and prevention 
 In addition to the specific actions related to the prescribed drug therapy.
 Demonstrate the proper method for administering the inhaled forms of these drugs and
taking only the prescribed dose drug

Evaluation

 The therapeutic effects of any of the drugs used to improve the control of acute/chronic
respiratory diseases and to treat/help prevent respiratory symptoms include the following:
 Decreased dyspnea
  Wheezing
 Restlessness and anxiety
 Improved respiratory patterns with return to normal rate and quality 
 Improved oxygen saturation levels
 Improved activity tolerance and arterial blood gas levels 
 Improved quality of life 
 Decreased severity and incidence of respiratory symptoms.