Adrenergic beta 2 fibers from thoracic ganglia innervate bronchial smooth muscle and pulmonary blood vessels ⬆️cAMP > bronchodilation nonadrenergic noncholinergic: NANC release NO and VIP (vasoactive intestinal peptide)>> relax airway smooth muscle

PSNS of airway:

cholinergic- Ach to Muscarinic 3 innervation via fatal nerve M3 > PLC > IP3 > ⬆️Ca++ in bronchial smooth muscle > bronchoconstriction and ⬆️ mucus secretion of bronchial glands blocked by: anti cholinergic/ antimuscarinic

asthma: variable airflow obstruction that is:

reversible

asthma: outflow disorder characterized by: 3

1. inflammation 2. bronchial hyper-reactivity 3. reversible airway obstruction

1. inflammation 2. bronchial hyper-reactivity due to:

activation of t2 lymphocytes and cytokinine release

goal of asthma/ outflow medications:

flatten response to mediators

asthma sx:

recurrent: wheeze breathlessness cough (PM and early AM) tachpnea prolong expiration tight chest fatigue

mediators of airway reactivity:

EOSINOPHILS MAST CELLS > these cause inflammation neutrophils macrophages basophils t lymphocytes probably mediators: CYTOKININES, INTERLEUKINS leurktrienes, histamine

COPD/emphysema/bronchitis factors

genes smoking age gender lung development exposure to smoke fumes pollution socioeconomic asthma infection

COPD: outflow disorder: NOT:

reversible or incompletely reversible by bronchodilators, will help but wont reverse

COPD cell death and destruction of alveoli by: 3

impaired lung parenchyma degraded matrix toxic actions of macrophages and neutrophils (inflammation)

COPD results in:

enlarges air spaces trapped air fibrosis increase mucus

COPD and inhaled corticosteroids:

will decrease exacerbation frequency

COPD and steriods:

limited effect on inflammation

COPD and bronchodilators:

modest role in outflow with breathlessness

3 long acting bronchodilator’s

salmeterol, formoterol, tiotropium

beta agonist broncho dilators

Beta Agonist bronchodilator’s: short acting albuteral bitolterol metaporterenol terbutaline long acting: salmeterol formoterol anti cholinergic bronchodilators: short acting atropine ipratropium bromide long acting: tiotropium methylxanthines: PDI: theophylline aminophylline

anti cholinergic bronchodilators

albuteral dose

100mcg puff 2 puff Q 4-6 hours neb: 2.5-5mg in 5ml saline

potentiates volatiles

albuteral

isomers of albuteral

R albuteral leabuteral B2 Salbuteral B1

adverse effects of beta agonist bronchodilators

tachy dysrhthmia hypokalemia hypomagnesium hyperglycemia tremor vasodilation

similar to albuteral but longer acting

bitolterol

100mcg puff 2 puff Q4-6 hour

albuteral

potentiates inhaled anesthetics

albuteral

given to blunt intubation

albuteral

longer acting than albuteral

bitolterol

less CV effects

bitolterol

270 mcg puff 16-20 puff/day

bitolterol

B2>B1 metered dose no more than 16 puff a day

metaproterenol

can be given subQ

terbutaline

200 mcg puff 16-20 puff a day

terbutaline

terbutaline subQ dose child and adult

child: 0.01 mg/kg adult: 0.25 mg Q15 min

why beta agonist bronchodilator long acting are long acting and what is DOA

lipophillic side chain resist degradation DOA 12-24 PREVENTION, not for use in OR salmeterol formoterol

COPD treatment:

anti cholinergic bronchodilators

longacting anticholinergic:

tiotropium

FDA approved for COPD

tiotropium - longacting anticholinergic

atropine neb dose

1-2mg in 5 ml saline

why atropine neb has high side effects and what are they

highly absorbed in respiratory endothelium tachy N dry mouth GI upset urinary retention blurr vision increase IOP

ipratropium dose

40-80mcg, 2-4puff

ipratropium adverse

more orally absorbed dry mouth GI upset