Okay we’re going to talk a little bit about your parasympathetics this is chapter seven these are the anticholinergic sees or what they’re known as backdoor bronchodilators we know in chapter six we talked about the sympathomimetics they mimicked the sympathetic system that’s where we got the bronchodilation from where we needed it uh in this case we’re going
To talk about the lytic side of the house we’re blocking what’s going to cause bronchoconstriction and that’s the reason why these are considered to be bactor bronchodilators so here’s some terms anticholinergic anything with the mimic and the lytic is on there too and you can see the different things that we’re going to talk about as far as that goes and then
Why do we use these this is class for family drugs it’s mainly used for patients who have copd they work in the higher up they’re out airway as a result of that things are working much much better for them and so this these this category of drugs is really the best for them this is kind of interesting when you talk about cholinergic anticholinergic you can see
With the parasympathetic system they like to call that sludge and this is what we see with it whereas with the anticholinergic you have a decrease in all of this so you don’t have the sludge that you have to worry about so basically um some of the indications for these copd maintenance hypotropium and teotropium are used for some patients who have asthma when
Tiotropium first came out it was only for patients with copd and then what they said was there’s a lot of folks who have asthma and they got it from their parents if they’re around parents or caregiver givers who smoked and so that some of the problems that we see with the asthma are actually related to copd so what they did is they started to use that as um part
Of the asthma treatments as far as that goes we’ve been using atrovin or epitrophium bromide for a long time with patients who have asthma when they come into the ed a lot of times we’ll mix this drug with the albuterol this is allowing us to get both actions of the bronchodilation directly and then the back door bronchodilator and keep the airways open much much
Longer so you also see here then there’s an indication for combined anti-cholinergics and beta agonist um for patients with copd with air flow obstruction and you know this is the cases where severe asthma is not responsive alone to the beta agonist at that particular point and these are what you’re using if you’re using nasal sprays for rhinitis to go ahead and
Help that dry out those airways so there’s epitropium bromide that’s atrovent and then you have epitopium bromide and albuterol it can either be a combined resmet which is a dry mdi if you want to think about it that way but it’s actually called a resmed or dual neb which is your spn and this is the combination of the epitropium bromide now butyron and then
You can see there’s other ones that have come into the formulary you have two doors uh pressed there glycopyrulate is really kind of an interesting one this is also known as robinol this has been on the market for a number of years seemed to disappear from our formularies for a long while in the last couple years it’s come back and as you can see there’s a lot
Of mixtures that we’re now using the glycopylate geotrophium was the first really 24-hour um anticholinergic esperibus bereava came out as a dpi and now it’s coming out as a resume also it was probably the second or third one i think i’ve seen on res mass as far as that goes and as you can see we can go ahead and mix that with the dollar all um then you have your
You implemented in the um bromide in the various forms that go with that also so epitropium bromide this is your atrovent and here’s your hfa that’s your carrier gas mdi as you can see here 17 micrograms per puff spn solutions it’s a two percent solution 0.5 milligrams or 500 micrograms normally qid nasal sprays just basically whatever your physician orders
For you and we do use it for patients with copd we also use it for patients with asthma and so it works really really well for us and there’s your combivent or dual neb at that particular point you can see the mixture of the alburo and the epitropium at that particular point and as you can see the combination is more effective for patients who have stable copd
And either aging alone the combination is really really healthy and that’s something we want to watch and think about so glycopyrulates and anticholinergic it controls conditions such as peptide ulcers that will lead to excessive stomach acid production you have an injectable form that’s used to reduce saliva nasal lung and stomach secretions and it’s also there
To help control heart rate during surgery they’re also used to reduce drooling in children’s ages 3 to 16 you have certain medical conditions such as cerebral palsy as you can see also it now comes as a mixture that we can give you’re going to see one of them here the lohola magner is a liquid utilizing a vibrating mesh nebulizer you see these oftentimes on our
Mechanical ventilators doesn’t add any dead space to the mechanical ventilator and the mesh actually just works and breaks up the particle sizes to where they’re within the therapeutic range and as you can see it’s usually administered parentally to reverse neuromuscular blockade that means we’re going to give it to you iv or other way and it has been approved
By the fda for treatment of copd and then in combination you can see the different combinations that you have at this particular point and these are also there to treat copd so your once daily ones as i said tierpotropium bromider spiriva was one of them it’s an m1 and m3 selectivity and the dpi is like 18 micrograms inhalation resmet you can see it’s um
Basically that’s your smi soft mist inhaler that actually has 2.5 micrograms inhalation two inhalations once a day as far as that goes and when i show you these two the different ones you’ll see what that goes with those but there’s your different mixtures that you can see and how that they are actually delivered so most of these are actually dpis pattern inhalers
Um and there you can see to zoro press air for the maintenance treatment of copd this is also one inhalation it’s a potent antagonist for all muscarinic receptors there’s basically five different musculature receptors very low in transient systemic exposure so it still has side effects but not quite the side effects let’s see with a lot of the other drugs so
Basically um these are from atropine that was the early one drug that started this as you can see it’s a tertiary ammonium compound easily absorbed into the bloodstream and it does cross the blood-brain barrier with the other ones don’t and there’s your anticholinergic antimuscarinic has a little bit more what we’re talking about this is has to do with atropine
It blocks hypersensitive of secretion stimulation relaxes airway smooth muscle that’s why we can use atropine from asthma if we need to one the side biggest side effect we see with this whole family is drying it really dries you up um they used to tell you if they were giving you atropine you’re probably going to be totally congested for at least four hours
And we would give it to these folks and sure enough they were like okay through for four hours because of the drying effect of them uh it causes acute psychotic reactions in the central nervous system uh you also see pupil dilation and blurred vision it can increase your interocular pressure if you have glaucoma so we have to be careful if we’re using these to
Keep it out of a patient’s eyes otherwise we’re going to have some big issues with it uh it is um used to increase the heart rate and sympathetomatic bradycardia we still use that that’s part of our cls algorithms when you learn that part of it too okay it can cause dysphagia decreasing gi motility and emptying at that particular point um so you really do have
To be pro watched these folks when you’re giving them drugs like this and this is just a cool little picture as you can see the atropine block the receptor in the muscles of the eye and you can see when the eye is more dilated than the other and that’s your atropine eye okay so some of the other effects that we see with quaternary ammonium compounds you get
Bronchodilation but you don’t have the central nervous system effect normally you don’t have that effect with the eyes no cardiac effect you still have that dry mouth in the general general total urinary portion of it there’s some musino effect and most of your side effects are localized to the site of where it’s given at this particular point this is more of
Atrovent and as we said erythrin causes bronchodilation it blocks cholinergic action reduces hypersecretion in nasal passages has and it works fairly well so if you need to remember what are the side effects of an anticholinergic this is a really cute thing it was on the internet from sketchy medicine as you can see you get as hot as a hair dry as a bone blonde
As a bad red as a bee mad as a hatter so how do these different drugs work um they cause basal level bronchomotor tone and the parasympatholytic blocks this tone and the degree of function dilation depends on the amount of the parasympathetic tone that’s present and so there if you’re healthy there’s just minimal minimal effects as far as that goes and one of
The things is atropine also inhibits exercise-induced asthma and psychogenic bronchospasm and bronchoconstriction caused by the blockage of your cholinergic agents we can see these sometimes when we talk about lidocaine and we’ll talk about lidocaine a little bit later in a different category deep breaths can stimulate your cough reception receptors and they can
Increase your bronchomotor tone um this is really good we can use it with our patients of asthma and copd just got to be careful as far as that goes and there’s three of your muscarinic sites as you can see uh these are one the different things that they cause so the adverse effect of these drugs we don’t normally see any of the blood pressure ekg or heart rate
We don’t see any problems with your ventilation perfusion abnormalities there’s no tolerance or loss of protection which is really really good side effects drying i cannot stress to you how drying this medication is it can also have a cough it’s um one of the things that’s interesting when you’re dealing with patients is you sometimes tell them you know we need
To use holding chamber or spacer when we’re giving this medication especially want to keep it out of their eyes and these guys will tell you yeah well if i don’t feel the back of my throat or it doesn’t make me cough then i know it’s not working that’s not quite how this works and sometimes you can convince them sometimes you can’t so you do have to be careful
With that when you’re dealing with folks uh some of the other things we can see as you can see with this is a little disney after life symptoms bronchitis upper respiratory infection it’s always interesting to find out that we’re giving you a drug to take care of your respiratory issues it’s going to cause you respiratory issues so how do we use them we use them
With copd they’re more potent the bronchodilators than they adrenergics and emphysema bronchitis and the fda’s approve these for copd what’s interesting now is although they’re approved for copd if you remember what happens is they will eventually work their way over to the asthma category too the problem is is you’ve got to know how it affects people who have
Asthma before you allow that to happen okay so the prolonged effects of these are these are llamas okay are useful in controlling your nocturnal asthma symptoms where your choleric mechanism increases the airway tone um we mix the two the short-term bronchodilators and epitropium are really good that helps your patients with copd also helps your patients with
Asthma are having some issues and we’re not being getting the asthma under control like we like to so there it is no label indication for asthma in the united states even though we do it uh they’re not clearly superior to your beta agonist okay so if you’re having asthma because we’re work slower in the airway the beta agonists are the first bit that we want to
Do and then we can add to it okay and as we talked about you can sometimes do with not nocturnal asthma psychogenic asthma being treated for other things as an alternative to the theophylline chapter eight is the same things and when we talk about the xanthes we’re talking about the offline and theophan has its own list of long side effects it’s a drug that has
To be given very carefully and there you can see we can also give it where we’re having problems with the beta agonist or unable to control this in some cases and we do know these two work hand in hand your beta agonist and your um parasympatholytic uh they complement each other and they actually increase what’s going along on with the patient makes it much much
Better for them one of the things we used to say is okay if you’re going to administer drugs one of the first things you wanted to do was to administer a bronchodilator and then you could follow up with your parasympatholytic then we would go to the steroids and anything else that we wanted to there’s no data that says that has to be done however we still do it
That way for the most part as you can see with a res mat or duo nab there’s no problem because these are pre-mixed and we’re going to be able to use it and not have to worry about well did you really do this first you do that first we’ve also come and it’s amazing what’s going on with ceo patients with copd is basically we said okay first of all we started with
The beta agonists found out they didn’t work quite as well as we wanted to and we came up with parasympathetics we found out those worked really well however the patients with crpd still needed rescue inhalers so we would give them the beta agonist then we went ahead and said okay well let’s look some inhale corticosteroids in addition to the parasympatholytics
And then they came back and said well that doesn’t really matter either that doesn’t have anything to do with the price of tea in china because patients with copd don’t need now corticosteroids so that lasted for about six months and all of a sudden we come up and said well you know that was probably too fast of an assessment let’s take another look at all of
That and now what we have is triple therapy and what they’re telling you is as you can see here the triple therapy the lava salamis and the ics’s improve your lung function and they actually stop the progression of copd and so because of that we’re now starting to make more mixtures that actually help us with that so how do we assess these folks effectiveness
Based on the indication for use what kind of copd do you have at this particular point we’re going to monitor flow rates we’re going to do a respiratory assessment you’ve got to make sure that when you’re dealing with anyone who has respiratory issues before after injury you want to watch them you want to see what happens to the heart rate the blood pressure the
Breath sounds the coughing sometimes these guys are cough cough cough um people go oh my gosh their heart went up too high we’re gonna stop them no no no no no no no how are you gonna stop the coughing and a lot of times it’s the drugs we’re giving you and then we’re gonna look and see what is this patient saying patient because i feel so much better and again
I’m going to tell you guys to remind you do not put words in the patient’s mouth and then we can do arterial blood gases check their spo2 with our pulse oxes do long-term pfts make sure they know how to do them look at you know what’s going on with them not everybody who’s old has copd or some form of it we do not everybody who’s young doesn’t have it we still
Have different things that go on and you guys are going to talk about that when you do with diseases at that particular point
Transcribed from video
Anticholinergic Parasympatholytic Bronchodilators 2021 new By Louise Foley
