Question

Case Study 2

Respiratory Drugs

Brett is a 12 y/o boy with a history of asthma, diagnosed 2 years ago.  He is an outgoing, active boy and participates in a swim club and soccer, but he has a difficult time adjusting to the limitations of his asthma.  He has learned to control acute attacks by using albuterol (Proventil) metered-dose inhaler, and because his asthma is often triggered by exercise, he has been using a budesonide (Pulmicort) inhaler and taking montelukast (Singulair).  

After competing in his swim meet at the local indoor pool, Brett began experiencing respiratory distress.  He alerted his coach, who retrieved the albuterol inhaler from Brett’s backpack.  After two inhalations, Brett was still in distress and the rescue team was called.

On admission to the emergency department, Brett is in obvious distress with pulse oximeter readings of 90% to 91%.  He has nasal flaring and bilateral wheezing is heard in is his lung fields, pulse rate is 122 beats/min, and he is orthopneic.  While treatment is started, the nurse asks him questions that he can nod or shake to answer.  He shakes his head “no” when asked if he used his budesonide inhaler today and shrugs when asked about his last dose of montelukast. Course hero

1. According to the onset of action, which specific group of drugs would you anticipate will be prescribed to treat Brett’s acute asthmatic attack and why?  (10 points).  Name an inhaler the patient be taught to use to for rescue? (5points)

2. Considering Brett’s history, medications, and the location where Brett’s asthma attack occurred, what might explain his acute attack? (5 points)

3. What is the mechanism of action of leukotriene receptor antagonists (LTRAs)? (20 points)

4. In the past, Brett’s asthma has been treated with use of a budesonide (Pulmicort Turbuhaler).  What is the mechanism of action of steroid inhalers?  (20 points)

5. What instructions is the patient and the parent give when the child is prescribed a steroid inhaler for use?  (15 points)

6. List 5 teaching instructions for Brett and his parents about the use of corticosteroid inhalers. (10 points)

7. Use keywords and a textbook as a resource to search for an asthma support group or online support group for children or for adults.  Include the URL and information about what the group does or services provided. (15 points)

Answer 1

3- The leukoterine receptor antagonists (LTRAs) are taken orally and inhibit the bronchoconstruction induced by the cysteinyl-leukotrienes by blocking the CysLT1 receptor on bronchial smooth muscle.It is nonsteroidal,they may also refferd to as antiinflammatory bronchoconstruction preventors.LTRAs work by blocking a chemical reaction that can lead to inflammation in the airways.Leukoteriens are biologically active fatty acids derived from the oxidative metabolism of arachidonic acid via the enzyme 5 - lipoxygenase.Arachidonic acid is relesed from cell membrane phospholipids mainly by phospholipase.Cyclooxygenase pathway produces thromoxane and prostaglandins from arachidonic acid.Corticosteroids inhibit phospholipase A2 and subsequent synthesis of eicosanoid inflammatory mediators,including both prostaglandins and leukoterienes.Non steroidal anti inflammatory drugs such as aspirin inhibit cyclooxygenase.Zileuton inhibits 5-Lipoxygenase.There are two groups of leukoterienes,one with and the other without aminoacids moieties.Leukoterine B4 carries hydroxyl moiety only and binds to BLT receptors.The signaling pathway via G -protein coupled BLT receptor activation produces potent chemotaxis response.Cysteinyl leukotrienes have aminoacids moiety and bind to cysteinyl leukoterines receptors .bronchoconstruction vascular permeability eosnophil recruitment and chronic inflammation are mediated through the G-protein coupled activation of cysteinyl leukoterines receptors.Asthma is the most common chronic lung disease characterised by reversible bronchoconstruction inflammation and airway remodeling thar results in hyperresponsiveness.

4- Inhaled corticosteroids supress airway inflammaion ,which is responsible for asthma assosiated changes of the airway vasculature.The anti inflammatory effects of corticosteroids are due to activation or repression of target genes involved in the inflammatory process.Inhaled corticosteroids are the most effcective controllers of asthma .

They supress inflammtion mainly by switching off multiple activated inflammatory genes through reversing histone acetylation via the recruitment of histone deacetylase 2 .Through supression of airway inflammtion ICs reduces airway hyperresponsiveness and control asthma symptoms.ICS are now first line therapy for all patients with persistent asthma,controlling asthma symptoms and preventing exacerbations.Inhaled long acting beta agonist added to ICS further improve asthma control and are commonly given as combination inhalers,which improve compliance and control asthma at lower doses of corticosteroids.Corticosteroids may regulate gene expression in several ways.Glucosteroids enter the cell to bind to glucococorticoid receptors in the cytplasm that translocate to the nucleus.The major action of corticosteroids is to switch off multiple activated inflammtory agents that emcode for cytokines,chemokines,adhesion molecules inflammatory enzymes and receptors.These genes are switched on in the airways by proinflammatory transcription factors such as nuclear factor kB and activator protein 1both of which are activated in asthmatic airways and switch on inflammatory genes by interacting with coactivator moleculesnthat have intrisic histone acetyltransferase activity.

5-Inhaled medications are vital in the tretment of childhood asthma,although they are only effective if they are used properly.

First we teach about how to use the inhaler ,When using for the time without a spacer

• Shake th inhaler for five seconds
• Prime the inhaler by pressing down the canister with the index finger to release the medication.Hold away from the face to prevent medictaion from getting into the eyes.Press the canister down again three times.
• Clean the inhaler after use ,remove the medication canister and acp from the mouthpiese.Do not wash the caister or immerse in water.Run warm tap water through the top and bottom of the plastic mouthpiese for 30 secondsto 60 seconds.Shake off excess water and allow the mouthpiese to dry completely.
• Remember to take the cap off the mouthpiese
• Be sure there is medication in the canister
• Inhale through mouth not,nose
• Take a slow deep breath at the same time you press down on the medication canister.
• Keep an adequate supply of medication
• Determine when an inhaler is empty.

6- There are some points to be remember while using corticosteroid inhalers.

1. Breathe in quickly and evenlyy through your mouth until you have taken a full deep breath.
2. Hold your breath and remove the inhaler from your mouth.Continue holding your breath aas long as you can up to 10 seconds before breathing out.This gives medicines time to settele in your airways and lungs.
3. Before using the medicine tell your doctor if you have ever had any unusual or allergic reaction to medicines in this group or any other medicines.
4. Dont let the patient inhale too quickly,dont let him hold the inhaler upside down or sidways.
5. Dont have him deliver more than one puff with each inspiration.
6. Have the patient situp straight.
7. Expalin the proper use.Before use the inhaler have him take a deep breath and exhale slowly.