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Drugs and Diseases (2)

Dr. Usama Elbayoumi

Drugs and Diseases (2)

Module (4)
The Respiratory
System

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Topics
Anatomy and Physiology Background
Allergic Rhinitis
Pharyngitis
Laryngitis
Rhinosinusitis
Common cold
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Tobacco use disorder
Infections: acute bronchitis, pneumonia, and
tuberculosis

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The Respiratory System

Functions
Filter particles from incoming air.
Transport air in and out of the lung
Deliver oxygen (to release energy) and eliminate CO2
Control body temperature and water contents
Regulation of pH***
Produce vocal sounds.
Participate in the sense of smell

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The Respiratory System

Respiration: the process of exchanging gases
between the atmosphere and body cells.

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Respiration Process
❶ Ventilation: the movement of air
in and out of lungs.

❷ Gas exchange between blood

and lungs.

❸ Gas transportation in
bloodstream.

❹ Gas exchange between blood

and body cells.

❺ Cellular respiration: using oxygen to

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release energy and produce CO2

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Organs of the respiratory system

[Link]

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Allergic Rhinitis

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Nose and Nasal Cavity

prn

The nose is supported

by bone and cartilage

Nasal cavity is Nasal Septum

posterior to the nose • Bone and cartilage.
• Divides the nose into
nostrils.

Functions: entrance of
air and filtration of air [Link]
by coarse hair. m/deviated-nasal-septum/

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Turbinate (Nasal conchae) divide the

nose into passageways which increase
the surface area of the nasal cavity.

The turbinate is lined with

pseudostratified ciliated epithelium.
The functions of the lining are:
• Produce mucous.
• Cilia filters the incoming air and
[Link] remove mucous.
ANATOMICAL-STRUCTURE-OF-NASAL-
AIRWAY_fig1_235408689 • Warm up and moisten the air by
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network.

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Paranasal Sinuses
[Link]
organs/the-nose/paranasal-sinuses/

Four Pairs

• Open to the nasal cavity

• Lined with mucous membranes
• Functions: The sinuses reduce the weight of the skull and serve as a
resonant chamber to affect the quality of the voice.
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in bone there is caven of space for air to make it lighter AND helps the tone

Allergic Rhinitis
IgE-mediated inflammation of the nasal mucosa
It is frequently associated with other allergic
(atopic) conditions such as asthma, allergic
conjunctivitis, and sinusitis, and can exacerbate
these conditions.

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Allergic Rhinitis

[Link]

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Allergic Rhinitis

[Link]

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Allergic Rhinitis

Allergic Shiner
Dennie-Morgan [Link]
Transverse Nasal
lines (folds) rgic_shiner Crease
[Link] [Link]
nnie%E2%80%93Morgan_fold ransverse-nasal-crease

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Allergic Rhinitis
Diagnosis
Based on clinical history and physical
examination
Confirmatory tests (e.g., skin prick test)

[Link] [Link]
clinics/allergy-testing/ services/skin-prick-test-spt/

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Allergic Rhinitis
Classification of Allergic Rhinitis
Timing and duration: seasonal versus perennial
Effect on daily activities, sleep, and QOL: mild
(no/minimal effect), moderate (bothersome), and
severe (significant effect)

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Allergic Rhinitis
Red Flags
Children < 2 years
OTC antihistamines are ineffective after a 2-week
trial
Complications (e.g., fever, facial pain, otitis
media, worsening asthma, etc.)
Moderate to severe allergic rhinitis or mild
symptoms lasting > 2 months
Unilateral symptoms
If there is no allergen (non allergic rhinitis)

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Treatment of Allergic Rhinitis

Non-Pharmacological Measures
Avoiding the allergen
Pollens:
 Keep windows closed during pollen season
 Air-conditioned living space with fan closed or equipped
with HEPA filter
 Plan outdoor activities (Check local pollen counts)
 Wear masks when outdoor
 Shower and change clothes after outdoor activities

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Treatment of Allergic Rhinitis

Non-Pharmacological Measures
Avoiding the allergen
Dust mites:
 Use allergen-proof pillow covers and
mattresses [Link]
-to-remove-dust-mite-allergies-
 Wash bedding in hot water weekly from-your-home

 Reduce humidity to < 50%

 Dust and vacuum regularly

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Treatment of Allergic Rhinitis

Non-Pharmacological Measures
Avoiding the allergen
Pets:
 Keep pets out of bedrooms
 Wash beddings
 Regular grooming of the pet to remove
dander

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Treatment of Allergic Rhinitis

Non-Pharmacological Measures
Avoiding the allergen
Mold:
 Control indoor moisture
 Fix leaks
 Clean areas prone to mold growth
[Link]
canada/services/publications/healthy-
living/addressing-moisture-mould-your-
[Link]

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Treatment of Allergic Rhinitis

Non-Pharmacological Measures
Other Measures
Nasal Irrigation (e.g., with neti pot)

[Link]
your-sinuses-with-neti-pots-safe
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Treatment of Allergic Rhinitis

Pharmacological Measures
Intranasal corticosteroids (INCS)
Oral antihistamines
Nasal decongestants (topical and systemic)
Mast cell stabilizers

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Intranasal Corticosteroids
Beclomethasone (Beconase ®)
Budesonide (Rhinocort® Aqua and Rhinocort®
Turbohaler),
Ciclesonide (Omnaris®)
Fluticasone propionate (Flonase® and Flonase
Allergy Relief ®), fluticasone furoate (Avamys®)
Mometasone furoate (Nasonex®)
Triamcinolone (Nasacort AQ® and Nasacort
Allergy 24H®)

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Intranasal Corticosteroids
Most effective medications for rhinorrhea,
sneezing, and congestion
Less effective for eye symptoms
Should be used ROUTINELY (not prn)
Onset: 1 week but a trial of 2 – 4 weeks is required
before judging the efficacy
They can be used with antihistamines (fast effect
or breakthrough symptoms)

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Intranasal Corticosteroids
Adverse Reactions
Nasal burning and stinging
Epistaxis (with long term use)
Nasal dryness (may use Vaseline
or Secaris as lubricant)
Rare: Septal perforation

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Intranasal Corticosteroids
Notes
Shake well before use
Omnaris® (ciclesonide): discard in 4 months
from the date it is opened. Do not open the
aluminum pouch

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Intranasal Corticosteroids
How to Use INCS
Blow nose before use (or use a decongestant)
Wash your hands
Shake well (except Rhincort Turbohaleer)
Remove the cap
Priming is required for all and re-priming if not
used for ≥ 7 days (ciclesonide: prime with 8
sprays. re-prime if not used for ≥ 4 days)
MedlinePlus. How to Read a Medication Label. [Link]. Updated October 2020. Accessed February
24, 2025. [Link]

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Intranasal Corticosteroids
How to Use INCS
Keep your head upright or
tilt slightly forward (do
not tilt back)
Breathe out
Block one nostril with
your finger [Link]
how-they-work-and-how-to-use-them/

MedlinePlus. How to Read a Medication Label. [Link]. Updated October 2020. Accessed February
24, 2025. [Link]

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Intranasal Corticosteroids
How to Use INCS
Insert the applicator into the
other nostril (may use the
opposite hand)
Aim the spray away from the
septum (specially steroids)
Press the spray applicator
Breath in gently [Link]
nasal-spray/

Recap the canister

MedlinePlus. How to Read a Medication Label. [Link]. Updated October 2020. Accessed February
24, 2025. [Link]
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Antihistamines
Histamine is stored in “Mast cells”. It is released in
response to allergic reactions, drugs, stress, or
infections
Histamine has two main receptors:

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Antihistamines
Histamine Receptors
H1 receptors: in upper respiratory tract, smooth
muscles, and peripheral nerves and skin. The
effect of stimulated H1 receptors include:
 Capillary dilatation: redness, and hypotension, and
reflex tachycardia
 Increased capillary permeability: edema, and hives
 Contractions of smooth muscles:
bronchoconstriction
 Irritation of nerve endings: rash
H2 receptors: located in GIT
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Antihistamines
Drugs in Canada
First Generation Second Generation
• Brompheniramine • loratadine (Claritin®)
• Clemastine • Desloratadine (Aerius®)
• Cyproheptadine • Cetirizine (Reactine®)
• Diphenhydramine • Fexofenadine (Allegra)
• Dimenhydrinate • Rupatadine (Rupall®) – Rx
• Chlorpheniramine • Bilastine (Blexten®) – Rx
• Doxylamine
• Hydroxyzine – Rx
• Promethazine – Rx

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Antihistamines
First Generation Antihistamines
Preferred in skin allergy and common cold
remedies
Not for allergic rhinitis (thicken nasal secretions)
Abuse potential (hallucination)
CNS adverse reactions: drowsiness, fatigue, and
cognitive and functional impairment. These
adverse reactions persist even with nighttime
administration

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Antihistamines
First Generation Antihistamines
Anticholinergic reactions: Dry mouth, dry skin,
constipation, blurry vision (can worsen
glaucoma), urinary retention (can worsen
enlarged prostate), dryness of the respiratory
mucosa (can worsen asthma) and increased
heart rate
Hyperactivity in some children

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Antihistamines
Second Generation Antihistamines
Preferred in allergic rhinitis
Less effective in skin allergy and they are not used
in common cold (histamine is not a mediator)
Insignificant anticholinergic effect
Less CNS adverse reactions (non-sedating).
Cetirizine may cause some sedation
Must be taken daily (not PRN) and more effective
is starting before the exposure

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Antihistamines
Indications for Antihistamines
Allergic rhinitis Second generation preferred
Skin allergy First generation preferred
Common cold First generation antihistamines
Cough suppressant Diphenhydramine, chlorpheniramine, and
brompheniramine
Motion sickness and vertigo Dimenhydrinate (Gravol®)
Insomnia • OTC: Diphenhydramine and doxylamine
• Rx: Hydroxyzine
Nausea and vomiting in • OTC: Dimenhydrinate
pregnancy • Rx: Doxylamine + pyridoxine (Diclectin®)
Nausea and vomiting Dimenhydrinate and promethazine

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Nasal Decongestants
Topical Decongestants Systemic Decongestants
• Long acting (12 hours): • Pseudoephedrine (better efficacy
Xylometazoline, oxymetazoline evidence) and phenylephrine
• Short acting (4 hours):
phenylephrine is short acting
Advantages Advantages
• Less adverse reactions • Longer duration of action
• Fast onset of action
Disadvantages Disadvantages
• Short duration • More systemic adverse
reactions

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Nasal Decongestants
Mechanism: Alpha agonists causing
vasoconstriction and reduce nasal congestion
Decongestants are not for children < 6 years

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Nasal Decongestants
Adverse Reactions
CNS stimulation: nervousness, headache,
restlessness, and insomnia
Sympathetic stimulation worsens uncontrolled
hypertension, enlarge prostate, glaucoma,
tachycardia (worsens arrhythmia), diabetes, and
hyperthyroidism
Topical agents: nasal dryness, burning, and
stinging and rhinitis medicamentosa (rebound
congestion if used for > 3 – 5 days)
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Nasal Decongestants
Drug Interactions
Decongestants + MAOI, linezolid, SSRI, TCAD,
SNRI, ergot derivatives (e.g., ergotamine,
bromocriptine), sympathomimetics: excessive
vasocontraction - hypertension crisis
Avoid decongestants within 2 weeks of MAOI

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Nasal Antihistamines
Azelastine/fluticasone (Dymista)

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Ophthalmic Preparations
Ketotifen (Zaditor) – antihistamine + mast cell
stabilizer
Olopatadine (Patanol and Pataday) –
antihistamine + mast cell stabilizer
Iodoxamide (Alomide) – mast cell stabilizer
Sodium cromoglycate (Cromolyn) – mast cell
stabilizer

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Other Medications
Nasal sodium cromoglycate (Rhinaris CS®):
mast cell stabilizer
Nasal saline (0.9% NaCl) nasal preparations:
the safest option for children and pregnant
women – moisten and clean
Nasal ipratropium: for severe rhinorrhea

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Other Medications
Leukotriene receptor antagonists (LTRA):
montelukast can be used in allergic rhinitis
particularly when the patient has asthma
Immune therapy (allergy shot): desensitization

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Rhinosinusitis

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Rhinosinusitis
Inflammation of the nasal passage and the
sinuses [Link]
infections-an-overview-of-sinus-problems-their-causes-and-
treatment

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Rhinosinusitis
It can be
 Acute: last < 4 weeks – usually viral (e.g., due to
common cold). It can be recurrent
 Subacute: last 4-12 weeks
 Chronic: last > 12 weeks – usually due to persistent
allergy, nasal polyps (overgrowth of the mucosal lining –
usually chronic), or anatomical issues that obstruct the
sinuses (e.g., deviated nasal septum)

nose it's not streat that cuse deviated

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Rhinosinusitis
Weak immunity (e.g., immunosuppressants),
dental infection, and exposure to smoke and
pollutants increase the risk
Bacterial infection is common
Complications: orbital complications include
cellulitis, abscess, and blindness.

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Rhinosinusitis

• Nasal congestion Halitosis

• Sinus pain/pressure
• Yellow/ green nasal
discharge
• Postnasal drip
• Cough
• Loss of smell (anosmia)
• Fatigue
• Sore throat
• Dental pain
[Link]

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Treatment of Rhinosinusitis
Red Flags
Symptoms last for > 7 days
Temperature > 38.5 for more than 72 hours
Temperature > 40.5
Patients with purulent discharge
Severe facial/maxillary pain

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Treatment of Rhinosinusitis
Self-care Measures
Steam (cool mist or humidifier) treatment
+/‐menthol or pine oil – proven efficacy
Nasal irrigation (e.g., sinus rinse) – sooth
mucosa, liquify secretions, and moisturize
Increase fluid intake
Facial compresses using warm pads
Elevate bedhead to improve nasal drainage

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Treatment of Rhinosinusitis
Symptomatic Treatments
Fever and pain: acetaminophen and ibuprofen
Congestion: systemic and topical decongestant
(limit to 3-5 days). Intranasal corticosteroids can
be used
Avoid first generation antihistamines

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Treatment of Rhinosinusitis
Antibiotic Therapy
When infection is suspected
Watchful waiting for 7 days
If symptoms persist, consider amoxicillin, and
amoxicillin/clavulanic acid

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Pharyngitis

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Pharynx

Located behind the

nasal and oral
cavity (shared
passage or air and
food.

Three parts

Aids in producing
sounds for speech

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Pharyngitis
Inflammation of the pharynx
Causes:
 Infectious: viral infection (most common – self-limiting
in 5-7 days), bacterial infection (self-limiting in 5-7
days), and rarely fungal.
 Non-infectious: allergic rhinitis, and irritants (acid
reflux, smoking, pollution, chemical fumes, etc.)

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Pharyngitis
Symptoms
Sore throat, dysphagia, hoarseness or loss of
voice, and cough
Viral infection: runny nose and nasal congestion
Bacterial infection: fever

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Pharyngitis
Treatment
Self-care Measures
Proper hygiene if infectious pharyngitis
Drinking warm fluids and avoid alcohol and
caffeinated beverages
Gargling with warm salt water
Humidifier
Avoid excessive/loud talking
Soft food
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Pharyngitis
Treatment
Symptomatic Treatments
Acetaminophen or ibuprofen
Lozenges or sprays containing menthol, honey, or
benzocaine
Antihistamines for allergic rhinitis

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Pharyngitis
Strep Throat
Bacterial pharyngitis caused by Group A
Streptococcus (GAS), Streptococcus pyogenes
It is highly contagious and spreads through
respiratory droplets, sharing utensils, and direct
contact with contaminated surfaces
Common in children 5 to 15 years of age

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Pharyngitis
Strep Throat
Symptoms: sudden and
severe sore throat with high
fever (> 38.3), swollen lymph
nodes, and pus on tonsils

[Link]
ccal_pharyngitis

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Pharyngitis
Strep Throat
Complications: rheumatic fever, and post-
streptococcal glomerulonephritis, tonsillar
abscess, sinusitis, and otitis media
Treatment: penicillin V (1st choice), amoxicillin,
cephalexin, azithromycin, and clarithromycin

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Laryngitis

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Larynx
It is an enlargement in the airway
between the trachea and to the
pharynx. It is composed of a
muscles and cartilage bound by
elastic tissue.
Functions
keep particles from entering
the trachea.
Houses the vocal cords.

[Link]

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Laryngitis
Inflammation of the larynx
It can be acute (< 3 weeks) or long-term (> 3
weeks)
Symptoms
 Primary: hoarseness, raspy or strained voice, weak
voice, and loss of voice (aphonia)
 Secondary: sore, dry, scratchy, and painful throat,
cough, and difficulty swallowing

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Laryngitis
Causes:
 Infectious: viral infection (most common – self-limiting
in 3-7 days), bacterial infection (can be self-limiting),
and rarely fungal
 Vocal strains: overuse (shouting, singing, prolonged
talking) and professional voice users (e.g., singers)
 Local irritation: allergic rhinitis, and irritants (acid
reflux, excessive alcohol intake, smoking, pollution,
chemical fumes, etc.)

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Laryngitis
Treatment
Similar to pharyngitis EXCEPT
Voice rest is important
Antibiotic is usually not recommended unless
bacterial infection is confirmed

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Common Cold and

Influenza

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Cold and Flu

Commonly mild, and self-limited viral infections of
the airway
Different pathogens but similar symptoms

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Cold and Flu

Symptom Common Cold Influenza
Discharge Clear then become mucopurulent
Congestion Common Rare
Fever Rare 38 – 40 (sudden)
Sore throat Common Sometimes
Headache Rare Yes
Body aches Mild Common (myalgia)
Others uncommon Fatigue, weakness, chills
Complications Sinusitis and otitis media Pneumonia and death
When Any time Mainly Nov - April
Duration 5 – 7 days (up to 14) 10 days

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Treatment of Cold and Flu

Self-care Measures
Hydration
Bedrest
Practice good hygiene

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Treatment of Cold and Flu

Pharmacological Measures
Antivirals for influenza
Antibiotics for complications (e.g., pneumonia
and sinusitis)
Symptomatic Treatments
 First generation antihistamines (for runny nose/cough)
 Systemic nasal decongestants
 Antipyretics: acetaminophen and ibuprofen
 Antitussives
 Expectorants
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Antitussive
Coughing clears the mucous and foreign materials
Used for frequent, dry, nonproductive cough
Options: codeine, dextromethorphan,
hydrocodone, 1st generation antihistamines,
menthol, camphor, ammonium carbonate, and
potassium carbonate, and honey
Multiple mechanisms: brain
 Suppress the cough receptors (stretch receptors and
irritant receptors) in the airway
 Suppress the central cough centers
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Codeine
The golden standard antitussive
Suppress the central cough receptors
Non-prescription options available
Not for children < 12 years old
It has abuse potential

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Codeine
Adverse reactions: constipation (patient can use
stimulant + softener), nausea and vomiting, and
drowsiness
Dryness of the respiratory mucosa + suppressing
the respiratory center due to CNS suppression can
worsen asthma and COPD

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Dextromethorphan (DM)
Many brands in Canada: Benylin, Robitussin,
Buckleys, Koffex, etc.
Commonly used (available without prescription)
Mechanism: Similar to codeine but
 Without analgesic properties
 Does not suppress respiration (unless used in high
dose)
 Less abuse potential (unless used in high dose)

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Dextromethorphan (DM)
Not for children < 6
years of age
Often combined
with other
ingredients (e.g.,
decongestants)
Should not be used
without prescription
for > 7 days

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all cogh is not for the age of yonger than 6

Dextromethorphan (DM)
Adverse Drug Reactions
Common: drowsiness, dizziness, nausea,
vomiting, nervousness and restlessness.
High dose can cause respiratory depression,
confusion, and slurred speech
High dose causes hallucination, euphoria, and
dissociative

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Dextromethorphan (DM)
Drug Interactions
Serotonin syndrome when combined with MAOI,
SSRI, SNRI, TCAD, linezolid, tramadol, and other
serotonergic drugs

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Hydrocodone
Hycodan® (hydrocodone-homatropine)
Straight narcotic
Very effective but it has high abuse potential
High sugar contents (better avoided in diabetics)
Causes significant drowsiness and impaired vision

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Honey
It provides mild cough suppression effect (coat
and soothe the irritated throat), anti-inflammatory
effect, and immune-supporting effect
Can be used in children as young as 1 year old
Children < 1 year old may develop botulism (due
to contamination by the spores of the Clostridium
botulinum bacteria which produce neurotoxin)

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Other Antitussive
Menthol: creates a cooling sensation, reduce
throat irritation, has mild numbing effect, and
provide a mild cough suppression effect
Camphor: acts as a mild bronchodilator,
provides a cooling and numbing effect on the
respiratory tract, loosen mucus and has a mild
cough suppression effect
Diphenhydramine: first generation antihistamine
with cough suppressing effect

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Expectorants
Expectorants/mucolytics thin the airway mucus
secretions, ease expectoration, and increase the
clearance of mucous when coughing
Must be used only for productive cough
Using a humidifier helps thinning the phlegm

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Expectorants
Water: it is the most effective expectorant.
Patients should remain well-hydrated by drinking
6-8 glasses of water per day
Guaifenesin: a commonly used expectorants.
Used alone or in combination with cough
suppressants. Efficacy is questionable

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it makes easer to crear the mucus

Expectorants
Ammonium carbonate: loosens the phlegm and
stimulates ciliary mucus clearance.
Potassium carbonate: loosens the phlegm and
improve mucous flow. It has soothing effect on the
throat

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Asthma

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Trachea
Runs anterior to the esophagus
Divide in the thoracic cavity to right
and left bronchi.
It is lined with ciliated mucous
membrane with many goblet cells
(mucous traps the particles)
Remains open by 20 incomplete C- tube
shaped cartilaginous rings. The
gaps between the ends are filled
with smooth muscle and
connective tissue.
[Link]

[Link]
[Link]?imageid=15D69040-2FA0-4A20-8465-
031B04098588&p=648830&pn=1&searchId=605db0fa7f14fcb16e1ca0aeff0283a3&searchtype=0

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cillia is responsible to clean

trachea is open all the time

Bronchial Tree
Primary bronchi  secondary and
tertiary bronchi  bronchioles 
alveolar ducts  alveolar sacs
(thin-walled pouches)  alveoli

The structure of the bronchi is like

the trachea but as the tubes branch
there is less cartilage, and more
muscles.

The bronchial tree is lined with

mucous membranes to filter the
incoming air.

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Bronchial Asthma
[Link]

Bronchial asthma is a progressive inflammatory disease with

reversible airway obstruction

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Bronchial Asthma
Pathophysiology
Airway inflammation

Airway Obstruction
Muscle contraction, edema, mucous secretions

Airway hyper-responsive
Destruction of epithelium and exposure of nerve ending
it's tissue ling the airway
Airway remodeling
Fibrous ssue + ↑ muscle mass and mucous  less reversibility
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Bronchial Asthma
Symptoms
Dyspnea, shortness of breath, chest wheezing,
and cough
Types
 Allergic asthma (most common)
 Exercise-induced asthma (EIA)
 Non-allergic asthma

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Bronchial Asthma
Triggers of Asthma Symptoms
Exposure to allergens (e.g., pollens, animal dander, dust
mites, etc.),
Respiratory infections (e.g., influenza, cold, pneumonia)
Occupational stimuli (e.g., flour dust, hay mold, azo dyes,
rubber, plastics)
Lifestyle: smoking, and exercise
Cold air
Emotional triggers (e.g., anxiety, stress)
Drugs (e.g., ______)
beta blocker

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Bronchial Asthma
Status asthmatics: a medical emergency
characterized by severe asthma that does not
respond to usual treatment  Severe hypoxia that
causes loss of consciousness and death. IV
magnesium sulfate is used for status asthmatics
(if bronchodilators fail)

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Treatment of Bronchial Asthma

Objectives
Control the symptoms
Prevent exacerbations
Maintain pulmonary function

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Treatment of Bronchial Asthma

Treatment Modalities
Self-care measures
Avoid triggers (most important but not enough)
Smoking cessation including secondhand
smoking
Manage risk factors: weight loss, reduce stress
and anxiety, etc.
Encourage regular physical activity
Healthy diet

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Treatment of Bronchial Asthma

Treatment Modalities
Pharmacological Measures
Bronchodilators Anti-inflammatory Drugs
• Target airway obstruction • Target inflammation
• Categories: β2 agonists, • Categories: corticosteroids,
anticholinergic , and xanthine leukotriene receptor
derivatives antagonists, IgE neutralizers,
and mast cell stabilizers

it like the bands

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Inhaler Devices Used in Asthma

Turbohaler
Ellipta

MDI

Diskus

Twisthaler

Breezhaler Respimat
Genuair Handihaler
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Inhalation Devices Used in Asthma

Metered Dose Inhalers Dry Powder Inhaler
The drug exists in fine powder or The drug is delivered as finely
droplets suspended in divided powder
compressed gas
Advantages Advantages
• Accurate dose • No need for coordination
• Inexpensive • Most drug deposition in lungs
• Portable (70% - 90%)
Disadvantages Disadvantages
• Oral deposition (a spacer can • Expensive
be used to enhance delivery) • Breath activated: may not be
• Require coordination suitable for patients unable to
• Require repriming if not used for
long time. breath forcefully

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Devices Used in Asthma

Spacer Nebulizer

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Devices Used in Asthma

Air Flow Meter
Uses
 Assess the severity of asthma
 Assess the response to therapy
It measures the Peak Expiratory Flow
Rate (PEFR) breath out
Patient should use it twice daily and
record the readings
If < 50% of the patient’s best, the
patient should consult
Image source:
the physician
[Link]
flow-meter-pf9940/

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Bronchodilators

β2 agonists Anticholinergic

Short acting
Selectivity Selective
(SAMA)

Duration
Nonselective
Long acting
(LAMA)
Route Oral
Inhaler
Duration

Short acting (SABA) Long acting (LABA)

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open the air way we want ot open the air way

snptic nurve symtemp will fight or flight simulate bind to b2 resepter

that lead dilation to relxing of the muscles
open the ariway

maskarnic recepter
anti ncolin will work contraction of the mucles

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Inhaled β2 Agonists
Short Acting (SABA) Long Acting (LABA)
• Salbutamol (Ventolin® MDI/ • Salmeterol (Serevent®)
Diskus/ nebules – Airomir® • Formoterol (Oxeze®)
MDI) Commonly used • Indacaterol (Onbrez®)
• Terbutaline (Bricanyl® • Vilanterol (exists only in
Turbohaler) combinations)
• Fenoterol (Berotec® MDI)

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Inhaled β2 Agonists
Adverse Drug Reactions
Nervousness
Anxiety
active the fight
Tremors
Increased heart rate
Irregular heart beats
Nonselective bronchodilators can affect alpha-
receptors and cause increase in blood pressure.

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!!!!

Short Acting β2 Agonists (SABA)

First choice for acute attacks (rescue = RELIEVER)
Used PRN not as scheduled therapy
Rapid onset (minutes) with a duration of 3-6 hours
Can be used 30 minutes before exercise to
prevent exercise-induced asthma
If used > 2 x/week for 4 weeks (or nighttime
symptoms, or symptoms interfere with daily
activities) = uncontrolled asthma infilimation
No anti-inflammatory effect gets worse

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Long Acting β2 Agonists (LABA)

Used to maintain control of symptoms =
CONTROLLER air way prevent the syptemps
Long duration (12 hours) but slow onset so not
suitable as rescue (except formoterol which has
a fast onset and can be used for rescue)
The patients must be using steroids
Available in combination with steroids
(combination products to follow)
Share the same side effects with the SABA

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Inhaled Anticholinergic Drugs

Drugs in Canada
Ipratropium
Atrovent® MDI and nebules
It is a short acting muscarinic antagonist
(SAMA)
Ipratropium is used PRN as rescue (RELIEVER)
It has a fast onset (but slower than salbutamol) – it
used as alternative to SABA in intolerant patients

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Inhaled Anticholinergic Drugs

Drugs in Canada
Long-acting muscarinic antagonists (LAMA)
Tiotropium: available as Spiriva® Handihaler and
Spiriva ® Respimat
Glycopyrronium: Seebri® Breezhaler
Aclidinium: Tudorza® Genuair
Umeclidinium: Incruse®
LAMA are long acting – used once daily
Tiotropium, glycopyrronium, and umeclidinium
are used for asthma and COPD as CONTROLLER
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Inhaled Anticholinergic Drugs

Adverse Drug Reactions
Anticholinergic adverse reactions
If come in the eye cause blurred vision and
glaucoma.

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Xanthine Derivatives
Mechanism of action: Complex, and not well
understood. Effect include:
Reversing the antigen-induced
bronchoconstriction
Stimulate the respiratory centers in the brain
Stimulate mucociliary clearance
Suppress inflammation

cusein of caffine

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Xanthine Derivatives
Drugs in Canada
Theophylline (Theo-Dur®, Uniphyl®, generics)
Aminophylline (Phyllocontin® SR)
Oxtriphylline (Choledyl Elixir®)

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Xanthine Derivatives
Require serum level monitoring
Have many interactions
Limited used because of adverse reactions and
the need for serum level monitoring
Adverse reactions:
 Cardiovascular stimulation: tachycardia, and
increased blood pressure
 CNS stimulation: headache, and insomnia
 Gastrointestinal effects: increased gastric acid,
nausea, and vomiting

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Anti-inflammatory Drugs
Drug Class Drugs in Canada
Corticosteroids Inhaled Corticosteroids (ICS)
• Beclomethasone (QVAR®)
• Budesonide (Pulmicort® Turbohaler/ Nebules)
• Ciclesonide (Alvesco® MDI)
• Fluticasone propionate (Flovent® MDI and Diskus)
and furoate (Arnuity Ellipta)
• Mometasone (Asmanex® Twisthaler)
Oral: Please, refer to the endocrine system)
Leukotriene receptor
• Montelukast (Singulair®)
antagonists (LTRA)
IgE neutralizing
• Omalizumab (Xolair®)
antibody
Mast cell stabilizers. • Sodium Cromoglycate (Intal®)
• Nedocromil sodium (Tilade®)
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Inhaled Corticosteroids
Mechanism (?)
Mainstay maintenance therapy
Used twice daily REGULARLY as CONTROLLER
NOT as needed inflimation
No bronchodilation effect
Mainly used as inhalers because of minimal
absorption and thus much safer
Oral agents are reserved for severe exacerbation

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Inhaled Corticosteroids
Adverse Reactions
Oral candidiasis (rinse mouth after use)
Hoarseness, throat irritation and burning, and dry
mouth. chabge voice
Same adverse reactions and precautions as oral
steroids (please, review from in the endocrine
system) – but less severe
Concerns over the effect on growth in children

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but not using then that would effect on theamout of oxygen that leat to effectot he hight

LTRA

It is 100 to 1,000
times more potent
than histamine

naruing the air way

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LTRA
Mechanism (?)
Used as CONTRLLER NOT as reliever
Steroid-sparing effect
Used daily for EIA
Replace steroids when family has concern about
growth

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LTRA
Montelukast is available as tablets (10mg),
chewable tablets (5mg), and granules (4mg).
It is best taken at bedtime +/- food
Chewable tablets and granules contain
aspartame (worsens phenylketonuria)

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stop ihme bing to binding the the mas test

IgE Neutralizers
Omalizumab-binds-to-IgE-thus-forming-immune-complexes_fig1_51524062 medication that make in lab
[Link]

What is monoclonal
antibodies?
Mechanism

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bind to igb prevent ot allergent pregentthe alltgen to pbing the igme

IgE Neutralizers
Used as CONTROLLER not as reliever
It used in patients unresponsive to steroids
Patients must have allergic asthma
Administered SC every 2 or 4 weeks
Keep refrigerated

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Mast Cells Stabilizers

Mechanism (?)
Used as CONTRLLER not as reliever
Require multiple daily dose
Adverse reactions: bad taste, dry mouth, nasal
congestion, and hoarseness)
Poor compliance due to adverse reactions and the
multiple daily doses
Less effective than steroids and take weeks to
work

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Combination Products
Combivent® Respimat: Ipratropium + salbutamol
Advair® Diskus: salmeterol + fluticasone
Anoro® Ellipta: aclidinium + vilanterol
Duaklir® Genuair: formoterol + aclidinium
Enerzair® Breezhaler: indacaterol + glycopyrronium +
mometasone
Symbicort® Tubohaler: formoterol + budesonide
Trelegy® Ellipta : fluticasone +umeclidinium + vilanterol
Ultibro® Breezhaler: glycopyrronium + indacaterol
Zenhale® Twisthaler: mometasone + formoterol

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Chronic Obstructive
Pulmonary Disease
(COPD)

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Alveoli

More muscles,
less cartilages
Surrounded by
dense capillary
network

Very thin-walled microscopic

sacs clustered at the end of the
narrowest respiratory tubes
(known as alveolar duct). They
increase the surface area for
gas exchange

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CO2 diffuses out of blood from area of high CO2 partial

pressure in venous blood (45 mmHg) to area of low CO2
partial pressure in alveoli (40 mmHg)
O2 diffuses into the blood
from area of high O2
partial pressure in alveoli
(104 mmHg) to area of
low O2 partial pressure in
blood (40 mmHg)

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COPD
A chronic lung disease characterized by
irreversible airway obstruction
Severe inflammation causes damage to the fine
structures of the respiratory system (alveoli and
bronchioles) leading to loss of elastic recoil,
obstruction and limitation to expiration.
Triggers: cigarette smoking (major), occupational
exposure, air pollution, and genetic factors
COPD has 2 forms: bronchitis and emphysema

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COPD

Emphysema
Destruction of Bronchitis
alveoli  loss of Inflammation of the
elastic recoil  lining of the
abnormal air bronchioles 
retention, lung difficult expiration
inflation, and and productive
inability to cough  increased
exchange O2 and risk of recurrent
CO2  tachypnea infections
with a flushed look.

[Link]

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Management of COPD
Smoking cessation is the key
Bronchodilators (SABA or SAMA) as rescue
therapy becasue the irvesirvilable so they can use freely
lama is more than
the other LAMA +/- LABA  inhaled corticosteroids 
xanthine derivatives
Antibiotics: if patient has purulent sputum +
worsening dyspnea AND/OR increased sputum
production
so in copd lama is not more importent corticostroiyeed
thatn theasma pt
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Management of COPD
Mucolytics: controversial – water is most effective
Oxygen therapy: used in advanced cases – it may
prolong survival
Roflumilast: phosphodiesterase (PDE4) Inhibitors
NEW CLASS - Nonsteroidal anti-inflammatory
particularly target inflammation associated with
COPD. It reduces the worsening of chronic
bronchitis

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Alveoli
Why do alveoli NOT collapse when we
empty our lungs of air?

[Link]

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Neonatal ARDS
Neonatal acute respiratory distress syndrome
A serious medical condition affecting premature
infants when they born earlythe air way will colaps

Symptoms: rapid, labored breathing, and

cyanosis

[Link]

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Neonatal ARDS
A leading cause of death among
premature infants
Treatment: supplemental
oxygen, mechanical ventilation,
and surfactant replacement
therapy to help their lungs
function properly.
Infants will recover with prompt
and proper treatment

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Tobacco Use
Disorder

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Nicotine Addiction
On average, cigarette smokers lose about 15 years
of life span
4000 chemicals with 43 carcinogens
Nicotine (the addictive component) stimulates the
SNS and PSNS, respiratory and cardiac systems,
and causes skeletal muscle relaxation
Absorbed from the lungs, skin, and oral and nasal
mucosa

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Nicotine Addiction
Tobacco smoking causes tolerance
Polycyclic hydrocarbons in tobacco are CYP-450
enzyme inducers
Nicotine increases the plasma cortisol,
epinephrine, nor-epinephrine, and dopamine 
interfere with the effect of many medications
Fagerstrom scale is used to assess the level of
nicotine addiction

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Nicotine Addiction
The Stages of Smoking cessation
Pre-contemplation: No plan
Contemplation: plan to quit in 6 months
Preparation: Will quit in a month
Action: started
Maintenance and relapse prevention

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Nicotine Addiction
Tips for Successful Smoking Cessation Plan
Motivation is a key
Set a date (should be within 2 weeks of decision)
Inform the family and friends and seek their support
Identify triggers (record why and when craving happens)
Record the reasons for quitting and review when tempted
Review previous attempts and analyze causes of relapse
Remove cigarettes from daily life
Find a substitute for smoking when the desire strikes
Anticipate challenges

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Pharmacological Choices
Nicotine replacement therapy
 Bolus: gum, inhaler, lozenges, and spray – used PRN
 Long acting: transdermal patches – used regularly
Bupropion (Zyban®)
Varenicline (Champix®)
Cytisine (Cravv®)

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Nicotine Replacement Therapy

daily use
Nicotine Patches (24%)
Drugs in Canada: Habitrol and Nicoderm (24
hours) and Nicorette (16 hours)

24 hurs is suteable for when woke up they have crave in of cigrate

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Nicotine Replacement Therapy

Nicotine Patches
Apply upon waking to dry, clean and non-hairy
area and rotate daily
Dose: 6 weeks at step 1 (highest strength), then 2
weeks at step 2 (medium) and 2 weeks at step 3
(lowest strength)
Patient should quit immediately - Ensure quitting
in first 2 weeks

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Nicotine Replacement Therapy

Nicotine Patches
Remove patch during strenuous exercise
Do not cut the patch
How to handle craving? take gummy
Fold and discard in the foil pouch
Adverse reactions: Headache, insomnia (remove
at night), and eczema at application site

remove the patch wash the skin smoke then put same patch back on

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Nicotine Replacement Therapy

Nicotine Gum (19%) prn
Drugs in Canada: Nicorette and Thrive

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Nicotine Replacement Therapy

Nicotine Gum
Used PRN for craving
Technique: Bite – Bite – Park x 1 minute then
repeat (30 minutes/piece)
No acidic beverage for 15 minutes before and
while chewing the gum
It sticks to denture
Discard carefully

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Nicotine Replacement Therapy

Nicotine Gum
Adverse reactions: indigestion, hiccups, throat
irritation, stomatitis, and headache. Change in
taste, itch and rash are most common during the
first week

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Nicotine Replacement Therapy

Nicotine Inhaler (25%) prn
Drugs in Canada: Nicorette it's absourb form mouse not from the lung

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Nicotine Replacement Therapy

Nicotine Inhaler
Used PRN
Satisfy the hand-to-mouth movement
Each cartridge lasts for 20 minutes
and contains 4mg of nicotine (2mg
absorbed buccally)
Dose: Up to 12 cartridge/week x the
first 6 – 12 weeks and taper by 1 –
2/day over 6 – 12 weeks.

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Nicotine Replacement Therapy

Nicotine Inhaler
No acidic beverage for 15 minutes before and
while using it
Cold weather reduced absorption (warm it up in
pocket)

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Nicotine Replacement Therapy

Nicotine Lozenges (20%)
Drugs in Canada: Nicorette and Thrive

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Nicotine Replacement Therapy

Nicotine Lozenges
Technique: place one piece in mouth and dissolve
slowly in mouth (move from side-to-side) - do NOT
chew or crush
Avoid acidic beverage for 15 minutes before and
while dissolving it
Do not place multiple pieces at once
Dose depends on the number of cigarettes per day

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Nicotine Replacement Therapy

Nicotine Spray (20%)
Drugs in Canada: Nicorette QuickMist

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Nicotine Replacement Therapy

Nicotine Spray prn

Technique: Spray directly in mouth (not on

lips/teeth) and do not swallow for few seconds
Do not inhale – it is absorbed through the mouth,
not lungs we should sprayto the tissue
Avoid acidic beverage for 15 minutes before and
after
Requires priming (spray in tissue) if new or when it
not used for 2 days

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Bupropion
Drug in Canada: Zyban®
Success rate is 25%
An antidepressant that is also approved for
smoking cessation aid
Mechanism: affects certain CNS pathways to
reduce the effects of withdrawal
Contraindications: seizures and eating disorders

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Bupropion
Treatment should begin 1-2 weeks before the quit
date
Adverse reactions: headache and insomnia
Dose 150mg po daily x 3 days then BID x 7-12
weeks

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Varenicline
Drug in Canada: Champix®
Success rate is 33%
Mechanism: mixed nicotine agonist/antagonist at
the α4β2 nicotinic acetylcholine receptor.
Comes in two packs:
 Starter pack: contains 0.5 (white) AND 1mg (blue)
 Continuation pack: contains either 0.5mg tablets
(white) OR 1mg tablets (blue)

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Varenicline

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Varenicline
Treatment duration is 12 weeks
Quitting options:
 Start 1-2 weeks prior to the stop date
 Start first, then quit after day 8-35 days
 Start first, then reduce the number of cigarettes by 50%,
75% and then 100%

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Varenicline
Adverse Reactions
Nausea, vomiting, abnormal dreams, constipation
and flatulence
The patient should D/C treatment and seek
medical attention if develop:
 Rash
 Angioedema
 Depressed mood, agitation, aggression, hostility,
changes in behavior, and suicidal ideation/attempts

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Cytisine (Cravv)
NHP (Golden Rain or Golden Chain
acacia)
Similar mechanism to varenicline
Multiple daily doses with complex
regimen
Target quitting on day 5 after starting

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Cytisine (Cravv)
Adverse Reactions: nausea,
vomiting, stomach pain, abnormal
dreams, and psychosis (monitor those
with history of psychiatric diseases)

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Pneumonia
Bacteria, viral, or fungal infection of the alveoli
Symptoms: productive cough, fever, chest pain,
and difficulty breathing
Severity ranges from mild to life-threatening
(depending on age, comorbidities, unilateral or
bilateral infections, immunity status, etc.)

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Pneumonia
Treatment
Non-severe infection: amoxicillin, doxycycline,
and macrolides
Severe: quinolones, and second and third
generation cephalosporins

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