Pearls

Prescribed Inhalers Are Not All the Same!

Not all inhaler medications are designed to help with respiratory distress. Some inhalers are prescribed steroids or other medications, which will not help the patient in respiratory distress right away.

Prescribed Inhalers Are Not All the Same!
Most prescribed inhalers fall into the general classification of bronchodilators. There are a number of these medications that patients may be taking, sometimes in combination. Sometimes patients in distress simply have old prescriptions and try as many as it takes to resolve their distress. This is not a safe practice as it can push their heart rate dangerously high.

Bronchodilators achieve their desired effects, which include prevention and relief of bronchospasm associated with asthma or COPD and prevention of exercise-induced bronchospasm, by stimulating the beta 2 adrenergic receptors in the lungs and the vascular smooth muscle. Three bronchodilators commonly found are discussed below:

albuterol sulfate (Proventil or Ventolin)

is a sympathomimetic drug, one which imitates the action of the sympathetic nervous system, that should be used cautiously with patients who have tachydysrhymias, CAD, or severe hypertension. It is administered in a metered dose inhaler where the patient takes one to two puffs themselves. A nebulizer can also administer it.

aminophylline

is a bronchodilator and a mild diuretic that is given after asthma or COPD patients have not responded appropriately to frontline medications such as albuterol sulfate. It is also sometimes used in congestive heart failure. It should be used cautiously in patients with a CAD history as well as hypertension or seizures. It has been noted that there is an increase in central nervous system and cardiovascular side effects when aminophylline is administered with a sympathomimetic drug. In the field, aminophylline is administered by an IV infusion.

terbutaline sulfate (Brethine)

is a sympathomimetic bronchodilator that is also used to inhibit premature labor. It should be used cautiously in patients with cardiovascular disease, especially dysrhythmias and hypertension. If this medication is given with other sympathomimetics, it may potentiate (that is, enhance the effect of one drug by another drug) adverse cardiovascular effects. If used with beta blockers, the bronchodilatation effect may be inhibited. SC or metered dose inhaler can also administer terbutaline sulfate.

The following is a list of bronchodilators that patients may be taking for their asthma or COPD:

albuterol, such as Proventil, Ventolin
aminophylline, such as Amoline, Somophylline
bitolterol, such as Tornalate
ephedrine, such as Vicks, Vatronol
epinephrine, such as Bronkaid Mist, Primatene
ipratropium, such as Atrovent
ipratropium and albuterol, such as Combivent
isoetharine, such as Bronkosol
metaproterenol, such as Alupent, Metaprel
oxtriphylline, such as Choledyl
pirbuterol, such as Maxair
salmeterol, such as Serevent
terbutaline, such as Brethine
theophylline, such as Theobid, Theo-Dur, Uniphyl

The asthma patient may also be taking corticosteroid medications. These drugs interfere with the synthesis of inflammatory mediators and prevent migration and activation of inflammatory cells. They also work to improve responsiveness of beta receptors, promoting relaxation of bronchial smooth muscle in the airways. Actually, corticosteroids are produced in the human body by the adrenal gland. These same natural substances can be prescribed by the physician for the patient to take to help in the management of asthma (usually hydrocortisone or cortisol are used). Synthetic corticosteroids are available and more commonly prescribed than the natural substances. During an acute asthmatic attack the patient is usually given methylprednisolone (Solu-Medrol) in the emergency department. After the acute phase, they are sent home with high doses of oral prednisone or methylprednisolone, which is rapidly tapered over the next 10 days to two weeks.

If you are treating patients who are on steroids for asthma, this should be a good clue that they have recently had a severe attack or their disease has been getting worse. Patients are not kept on steroids for a long period of time due to the many unpleasant side effects of the drugs. Short-term adverse effects from oral or intravenous steroids include increased appetite, weight gain, elevated blood sugar, fluid retention, mood changes, and gastrointestinal upset. Most patients can avoid long-term (months or years) use of corticosteroids, which have additional adverse effects and risks. These include a suppressed immune system, adrenal suppression, osteoporosis, muscle weakness, cataracts, skin changes, and peptic ulcers.

In recent years, many clinicians are acclaiming the administration of corticosteroids by inhalation as the greatest advance in asthma management in the last 20 years. Many physicians are recommending inhalation corticosteroids as the first-line maintenance therapy for the adult with daily or frequent asthma symptoms. Their dosage varies from 1 to 5 puffs, two to four times a day, depending on the preparation. These are not designed to be administered during an acute attack, as a bronchodilator such as albuterol would be. The inhaled steroids are given at the lowest possible dose capable of controlling the asthma. Examples of inhaled steroids include: Beclovent, Vanceril, Azmacort, and AeroBid.

For more information on medications used to treat asthma and COPD, check out these internet websites:

www.allergy.mcg.edu
www.med.virginia.edu/cmc/tutorials/asthma
www.pdr.net
www.healthsquare.com/drugmain.htm

More on Assisting Your Patient with a Prescribed Inhaler

Prescribed inhalers can help patients in respiratory distress. The proper delivery of these medications is not an easy task, especially when a patient is not calm!

More on Assisting Your Patient with a Prescribed Inhaler
You have learned how to assist your patient with a prescribed inhaler. The device used is a multiple-dose inhaler or MDI. Most of the time, this is an easy procedure and the patient will often look to grab it out of your hands, if they have enough strength and really need the treatment.

However, in some instances, it is not as easy. Some patients require your attention in helping them calm down so they can best utilize the medication being administered. When a patient takes short puffs and the medication barely makes it down into their lungs, it cannot be effective. You may need to coach the patient into trying to inhale slowly and to hold the medication in for a few moments so it can be adequately absorbed by the respiratory tree.

This is not always an easy thing to do, since patients who have difficulty breathing are very anxious. Think about this: have you ever tried to swim from one side of a pool to the other underwater and, as you were three-quarters of the way across, start to really want to go up to the top and take a breath? If so, that was just a small taste of what it is like to be short of breath. Perhaps you should consider what it would be like to be underwater using a cocktail straw as a snorkel. It would be very difficult to exhale. The patient with lower airway disease goes through a similar feeling when in acute distress. His or her lower airways are constricted and clogged with secretions, so exhaling the air is extremely difficult.

Some patients utilize a device called a spacer or aerosol cloud enhancer (ACE). When using a device of this type, follow this procedure:

Ensure that the face mask is attached to the spacer properly.
Proceed to shake the MDI canister to mix the medication per the manufacturer?s guidelines.
Insert the nozzle of the MDI into the appropriate opening on the spacer.
Position the mask so that it fits over the patient?s mouth and nose and the exhalation flaps are not covered.
Have the patient exhale normally and then press down firmly on the canister.
The patient should take a slow, deep breath through the face mask. Some units have a coaching whistle on them that alerts the patient to slow down their inspiration.
After taking the deep breath, the patient should hold the breath in for 10 seconds and then exhale.
The mask should be kept on the face for a minimum of six more breaths to assure that all the medication that may have collected in the spacer has been administered to the patient.
If the physician's orders are to take two puffs, then repeat the procedure again.

For more information on the use of MDIs and spacers, check out the following internet website: