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[Audio] Welcome to the Pharmacology for Technicians Seventh Edition Watch and Learn Lessons!.

[Audio] Chapter 11, The Respiratory System and Drug Therapy..

[Audio] In the first section of this chapter, you will learn about the anatomy of the respiratory system. Throughout this chapter, you will learn about the differences between the main pulmonary diseases. In the asthma and drug treatments section, you will develop an understanding of the pathophysiology and treatment of asthma. You will also get an overview of the pathophysiology and treatment of chronic obstructive pulmonary disease..

[Audio] In the other lung diseases and drug treatments section of this chapter, you will develop an awareness of the reemergence of tuberculosis and its associated treatments. In the cough, cold, and allergy and corresponding drug treatments section, you will learn about the mechanism of action and uses of antitussives, expectorants, decongestants, and antihistamines. You will also discover why some drugs are prescribed for their side effects. In the tobacco use, smoking cessation, and corresponding drug treatment section, you will develop an awareness of smoking cessation plans and supportive therapy..

[Audio] Chapter 11, Section 1, Anatomy of the Respiratory System..

[Audio] The respiratory system contains specific organs that are responsible for obtaining oxygen from the air through inhalation. This allows these organs to supply oxygen to the cells in the body through gas exchange and by removing carbon dioxide from the body via exhalation..

[Audio] The respiratory system can be divided into the upper respiratory tract and the lower respiratory tract. The upper respiratory tract includes the nose, nasal cavity, mouth, pharynx, and larynx. The lower respiratory tract is made up of the trachea, bronchial tree, alveoli, and lungs. The lower respiratory tract is essential for the exchange of oxygen and carbon dioxide. The lower respiratory tract works with the circulatory system to transport oxygen to the cells of the body while removing carbon dioxide. During inhalation, air flows through the nasal cavity, pharynx, larynx, and trachea. It ultimately flows through the bronchial tree to the alveoli. The alveoli are the site where oxygen and carbon dioxide are exchanged within the blood..

[Audio] The respiratory system contains protective mechanisms to filter air and protect the airways and lungs from harmful substances like dust, bacteria, viruses, and allergens. In the nostrils, hair helps trap large particles like dust. The trachea contains small, hairlike structures called cilia that move in a sweeping motion to help clear out harmful substances. The lining of the respiratory tract contains cells that secrete a protective mucus. The mucus helps to keep the airway moist and helps to trap and filter waste..

[Audio] Chapter 11, Section 2, Asthma and Drug Treatments..

[Audio] Asthma is an inflammatory disorder of the airways that involves reversible airway obstruction. Because of the obstructed airways, less oxygen is available to exchange with carbon dioxide. In the asthmatic airway, bronchioles constrict, mucus production increases, and lung tissue swells. This makes normal breathing difficult. The image shown here and in Figure 11.3 is of an asthmatic airway..

[Audio] The main symptoms of asthma are wheezing, dyspnea, and cough. In asthma, times of poor airflow and difficult breathing alternate with times of normal function. An asthma attack is an episode of acute difficulty with breathing. Asthma attacks are characterized by hyper-reactivity of the airways and bronchospasm. Common triggers of asthma attacks include smoke, dust, exercise, pet dander, cold weather, gastroesophageal reflux disease, colds, and flu..

[Audio] Asthma is categorized into four levels of severity. These levels are intermittent, mild, moderate, and severe. The levels are based on how a patients' symptoms are affecting their ability to sleep at night, perform daily activities, and breathe freely. The level of severity is assessed by pulmonary function tests, nighttime symptoms, and use of relief medications. The picture to the right is a peak flow meter, which is commonly used to assess the severity of asthma. A peak flow meter measures peak expiratory flow rate. The patient forcefully blows into the peak flow meter and PEFR is recorded in liters per minute..

[Audio] The two components of drug therapy for asthma are quick-relief medications and long-term persistent medications. Quick relief medications are used intermittently and provide rapid relief for asthma symptoms or when an asthma attack occurs. Long-term persistent medications are used regularly to prevent asthma symptoms or attacks. Pharmacy technicians can help patients treat and prevent asthma attacks by promoting correct use of quick-relief medications and adherence to long-term persistent medications..

[Audio] An important method of administering asthma medications is by a metered-dose inhaler, also called a puffer. The MDI delivers a specific amount of medication with each activation. A spacer is a device attached to the MDI that holds the drug mist until the patient is ready to breathe. The spacer helps to decrease the amount of spray deposited on the back of the throat and swallowed. It also allows the patient to breathe the mist in at a slower and more effective rate. Another delivery device is a dry powder inhaler. DPIs do not use gas propellants. A nebulizer is a device in which a stream of air flows past a liquid and creates a fine mist. The patient inhales this mist while breathing normally through a mouthpiece or mask..

[Audio] Albuterol, levalbuterol, and metaproterenol are short-acting beta-2 agonists. These medications work by stimulating beta-2 receptors in the lungs and relaxing bronchial smooth muscle. They are considered bronchodilators. The short-acting beta-2 agonists are used to provide quick relief of asthma symptoms. These medications are available in a variety of inhaled and oral products. Their main side effects are tremors and nervousness. There are several cautions and considerations to be aware of with the short-acting beta-2 agonists. For children less than 5 years old, a spacer should be used. For children less than 4 years old, a spacer with a facemask is recommended. A caution specific to levalbuterol is that hypersensitivity reactions have been reported. Some formulations of metaproterenol contain benzyl alcohol, which is a consideration particularly important for neonates..

[Audio] Beclomethasone, budesonide, ciclesonide, fluticasone, and mometasone are inhaled corticosteroids. These medications act as anti-inflammatory agents to suppress the immune response and are used in the long-term control of asthma. Corticosteroids are available in a variety of inhaled dosage forms. The main side effects are oral candidiasis, hoarseness, and dry mouth. To reduce the likelihood of these effects, the patient should be advised to rinse their mouth thoroughly with water after using a corticosteroid inhaler. Another concern with the corticosteroids is the potential for stunting the growth of children. Initially, growth may slow down by a half inch in the first year, but children will eventually reach normal adult height. An important consideration with agents available as a DPI is that they should not be shaken before use. Along the same lines, patients should pay careful attention to the instructions for puncturing the powder packet or capsule of a DPI..

[Audio] The leukotriene inhibitors, montelukast, zafirlukast, and zileuton are used for the long-term control of moderate to severe asthma. They block the synthesis of the body's inflammatory responses to leukotrienes. Leukotriene inhibitors are available as oral dosage forms. The main side effect of montelukast is headache. The common side effects of zafirlukast and zileuton are headache, rhinitis, and cough. This class of medications is not to be used in acute asthma attacks. An additional caution is leukotriene inhibitors are associated with liver problems, eosinophilia, and vasculitis. They have also been associated with behavioral changes such as unusual dreams, agitation, anxiety, and hallucinations..

[Audio] Cromolyn sodium is the only mast cell stabilizer available to treat asthma. It comes as a nebulizer solution and is used in mild persistent or more severe asthma. Cromolyn sodium works by protecting mast cell membranes against rupture from antigenic substances. As a result, less histamine is released in airway tissue. The side effects of cromolyn sodium include hoarseness, dry mouth, and stuffy nose. This medication should be used with caution in patients with kidney or liver dysfunction..

[Audio] A monoclonal antibody is a pure antibody against a known specific antigen. Monoclonal antibody treatment is an injection-based treatment that is used in addition to inhalers and tablets. This class is used to help with uncontrolled asthma that has not responded to maximum doses or treatment with other therapies. The generic names of the available products are listed in the table. These medications work by inhibiting interleukin-5, which is a major cause of allergic asthma. Omalizumab blocks immunoglobulin G which is also involved in allergic asthma. Side effects common to this class include injection site reactions, viral infections, sinusitis, headache, and pharyngitis. Benralizumab, omalizumab, and rezlizumab carry boxed warnings for hypersensitivity and anaphylactic reactions. These reactions can be immediate or delayed. Live vaccines should not be given to patients taking dupilumab..

[Audio] A xanthine derivative is structurally similar to caffeine and causes relaxation of smooth muscle within the airway. This leads to airway dilation and better air movement. Theophylline is the main drug within this class. Theophylline is used in asthma, chronic bronchitis, and emphysema. Theophylline is available in several oral forms as well as an injection. The main side effects of theophylline are nausea, vomiting, headache, and insomnia. Theophylline toxicity is also a concern, and drug levels should be monitored..

[Audio] Chapter 11, Section 3, Chronic Obstructive Pulmonary Disease and Drug Treatments..

[Audio] Chronic obstructive pulmonary disease, commonly known as COPD, refers to a group of chronic lung diseases that impede airflow and cause breathing difficulty. COPD is irreversible, meaning that lung function does not significantly improve with administration of bronchodilators. COPD progressively worsens even with treatment. However, COPD is largely preventable through the avoidance of smoking, pollution or occupational hazards..

[Audio] COPD has several subtypes, including chronic bronchitis and emphysema. Bronchitis causes the lining of the bronchial airways to become inflamed. This obstructs airflow during expiration. Bronchitis is characterized by a cough that produces sputum. Acute bronchitis is caused by an infection that is usually viral. Acute bronchitis runs a brief course and is typically terminated by the body's immune responses. Sometimes antibiotics are used to prevent or treat secondary bacterial infections. Chronic bronchitis is a serious disease associated with excessive mucus production leading to cough with expectoration. Emphysema is characterized by destruction of the tiny alveoli, or air sacs, of the lungs. Inflammation destroys these air sacs, which then lose their ability to conduct gas exchange. In figure 11.4, note the difference between the healthy bronchiole and the bronchiole affected by chronic bronchitis. Note of the difference between the healthy alveoli and those with membrane breakdown in emphysema..

[Audio] The generic names of anticholinergics and combination products for COPD are provided on this slide. See Table 11.2 for brand names, common dosage, and dispensing status. The anticholinergics inhibit acetylcholine, which is a chemical that stimulates smooth muscle cells in the lungs to constrict. They are considered first-line therapy in COPD. Ipratropium is also used in the emergency treatment of asthma. The anticholinergics come in a variety of dosage forms for inhalation. The side effects of the anticholinergics are headache, flushed skin, blurred vision, tachycardia, and palpitations. Important considerations with anticholinergics is that ipratropium, aclidinium, and umeclidinium are not indicated for acute bronchospasm. Patients should be instructed that capsules of any of these agents containing powder should not be swallowed. They are to be used with an inhaler device and inhaled. Glycopyrrolate and revefenacin have cautionary statements about avoiding their use in multiple conditions..

[Audio] Alpha-1 antitrypsin is the only antitrypsin deficiency agent available and comes under a wide variety of brand names. This class of medications is used in the treatment of emphysema in patients in alpha-1 antitrypsin deficiency. It works by preventing leukocytes and neutrophils from infiltrating the lungs. Alpha-1 antitrypsin is only available in injectable form. Its side effects include headache, pharyngitis, and increased cough. When using alpha-1 antitrypsin, there is a risk for transmitting infectious agents since it is made from human plasma. In addition, this medication cannot be mixed with other agents or diluting solutions..

[Audio] Arformoterol, formoterol, olodaterol, salmeterol are long-acting beta-2 agonists. These medications work by stimulating beta-2 receptors in the lungs and relaxing bronchial smooth muscle. They are considered bronchodilators. The long-acting beta-2 agonists are used in the treatment of COPD and asthma. The long-acting beta-2 agonists are available in a variety of inhaled products. Their main side effects are dizziness, heartburn, nausea, tremors, increased blood pressure, and tachycardia. All the agents in this class carry a boxed warning for increased risk of asthma-related deaths. The long-acting beta-2 agonists should not be used for acutely deteriorating patients..

[Audio] Another treatment for chronic bronchitis is the use of a mucolytic such as N-acetylcysteine. A mucolytic reduces the thickness and stickiness of secretions and makes them easier to remove. While N-acetylcysteine is used in COPD, another mucolytic, dornase alfa, is used in cystic fibrosis. Both drugs are only available as inhaled products. Common side effects of N-acetylcysteine are bronchospasm, bronchitis, nausea, vomiting, and runny nose. Mucolytics should be used with caution in patients with a history of bronchospasm because these patients may have an increased risk of hypersensitivity..

[Audio] Roflumilast is a phosphodiesterase-4 enzyme inhibitor used to treat COPD. Roflumilast works by reducing lung inflammation. Roflumilast should only be used to treat severe COPD. When used in less serious cases, the side effects may not outweigh the benefit of the drug. These include diarrhea, nausea, headache, back pain, weight loss, dizziness, and decreased appetite. In addition, it is important to know that there have been neuropsychiatric effects such as anxiety, depression, and insomnia reported as well. In addition to the neuropsychiatric side effects, cases of suicidal behavior or ideation have been reported. Patients should report any psychiatric symptoms to their healthcare provider. Due to the potential for weight loss, patients should monitor their weight regularly..

[Audio] Several combination products are available to improve patient adherence and ease of administration. Combination products have the same side effects, contraindications, cautions, and drug interactions as the individual drugs. Most of these products contain a long-acting beta-2 agonist. See Table 11.2 for examples..

[Audio] Chapter 11, Section 4, Cystic Fibrosis and Drug Treatments..

[Audio] Cystic fibrosis is a genetic disorder involving the pulmonary and GI systems. The pulmonary aspects of this disease are hypoxia leading to cyanosis, digital clubbing, and cyclic lung status. This cyclic pattern varies from a state of relative well-being to one of pulmonary deterioration. The GI aspects of CF include increased viscosity of secreted mucus and a relative deficiency of pancreatic digestive enzymes. The viscous mucus blocks bile ducts. The digestive enzyme deficiency puts patients at risk for not meeting their nutritional needs..

[Audio] Antibiotics are used to combat the pathogens that take root in the thickened respiratory mucous secretions present in CF. There are a number of systemic antibiotics that are given intravenously. More information on these antibiotics can be found in Chapter 16. Regular treatment with nebulized antibiotics directed against Pseudomonas aeruginosa appears to improve lung function and is recommended for many patients who have CF. Inhaled antibiotics commonly used in the treatment of CF include aztreonam and tobramycin. The side effects of inhaled aztreonam are cough, nasal congestion, wheezing, and nasal passage and throat pain. Due to the potential for bronchospasm with treatment, inhaled aztreonam should be given after giving a bronchodilator. The side effects of inhaled tobramycin overlap somewhat with those of inhaled aztreonam. They include cough, sore throat, hoarse voice, shortness of breath, throat pain, runny nose, and headache. Inhaled aztreonam should be given after a bronchodilator, chest physiotherapy, and other nebulized medications..

[Audio] Dornase alfa is a mucolytic which breaks down DNA in the sputum of CF patients. By doing so, it helps reduce the thickness of secretions. Most patients with CF take pancreatic enzyme supplements. These products contain a mixture of lipase, protease, and amylase in varying amounts. These enzymes prevent bile duct obstruction and the occurrence of fatty and foul-smelling diarrhea..

[Audio] Several gene therapies have been created that target specific gene defects associated with CF rather than treating symptoms like many therapies. Gene therapy is the process of altering genes inside the body to treat or prevent disease. CFTR modulators are available as oral dosage forms. Their side effects include headache, nausea, sinus congestion, and dizziness. Increased values on liver function tests and cataracts in pediatric patients should be monitored. CFTR modulators should be taken with foods that contain fat, but not with foods that contain grapefruit or Seville oranges..

[Audio] Chapter 11, Section 5, Other Lung Diseases and Drug Treatments..

[Audio] In addition to the various lung disorders previously discussed in this chapter, many others exist. Several measures can be taken to prevent and control lung disease and infection. Preventive measures include not smoking, avoiding secondhand smoke, getting the influenza and pneumococcal vaccines, hand washing, and avoiding close contact with infected hosts. Pneumonia is a common infection of the lower respiratory tract. Microorganisms gain access to the lower respiratory tract by one of three routes: inhalation of aerosolized particles, entry through the bloodstream, or aspiration of oropharyngeal contents. Pneumonia is treated with antibiotics, depending on the causative organism. Pneumonia acquired outside of an inpatient facility is called community-acquired pneumonia. Pneumonia acquired while an individual is hospitalized or living in a hospital is called nosocomial pneumonia..

[Audio] Respiratory distress syndrome occurs in neonates during the first few hours of life. RDS is characterized by inadequate production of pulmonary surfactant. Without surfactant to keep the lungs and alveoli open, the alveoli will collapse, resulting in the inability to obtain enough oxygen. This lack of oxygen can lead to damage to the baby's brain and other organs. RDS requires immediate treatment. Risk factors for RDS include prematurity and maternal diabetes. RDS is treated with one of the three replacement surfactants such as, beractant, calfactant, or poractant alfa..

[Audio] Tuberculosis, or TB, is an infection caused by Mycobacterium tuberculosis. TB most commonly affects the lungs, but it can also infect other body tissues and organs. TB is transmitted by respiratory droplets. Persons at risk for TB include alcoholics, prison inmates, immunocompromised individuals, and older adults. Symptoms of active disease include weight loss, blood in sputum, night sweats, night fever, chest pain, and malaise..

[Audio] A tuberculin skin test is used to detect patients who have been exposed to TB but show no signs of the disease. The agent used for TSTs is purified protein derivative. This test is injected intradermally. A positive PPD is marked by an area of induration at the injection site within 72 hours. A marked area of induration is visible as a circular area of hardened tissue at the site of injection. A chest X-ray is performed if the PPD is positive. The initial phase of TB treatment consists of four drugs taken for two months, and is followed by two drugs taken for four months. The most commonly used agents are ethambutol, isoniazid, pyrazinamide, rifampin, and rifapentine. Patient adherence is a major problem in treating TB. The drug side effects, length of treatment, and number of medications all diminish adherence..

[Audio] Multidrug-resistant tuberculosis is caused by strains of M. tuberculosis that are highly resistant to many drugs. It is difficult to treat multidrug-resistant tuberculosis and has become a serious health problem. Multidrug-resistant tuberculosis may require 18 to 24 months of treatment. Risk factors for MDR-TB include failing to complete TB therapy, being prescribed inappropriate agents, having immune deficiencies, and having a recurrence of TB..

[Audio] Histoplasmosis, or the summer flu, is caused by a fungus that most commonly occurs in accumulated droppings from bats and various birds. When the fungus-bearing dust is inhaled, spores are transported into the bronchial tubes. The lymphatic tissue reacts to this invasion, and sensitivity develops; as a result, tissue becomes inflamed. Although the disease mimics tuberculosis, most patients recover on their own without treatment. Amphotericin B and itraconazole appear to be the only effective drugs for the more serious disseminated form..

[Audio] Chapter 11, Section 6, Cough, Cold, and Allergy and Corresponding and Drug Treatments..

[Audio] The common cold is a mild, self-limited viral infection and is the most prevalent respiratory tract infection. Its symptoms are readily recognizable and include mild malaise, runny nose, sneezing, scratchy throat, and fever. Bacterial sinusitis and otitis media are frequent complications of a cold and can sometimes require antibiotics..

[Audio] Allergies result from a state of hypersensitivity induced by exposure to a particular antigen. Some symptoms of allergies, such as runny nose and itchy eyes, are the same as those of the common cold. Sometimes allergies are mistaken for a cold..

[Audio] Antitussives work in one of several ways to stop the cough reflex and reduce the frequency of cough. The antitussives currently available are listed on this slide and the next. The antitussives include codeine, the combination of hydrocodone and chlorpheniramine, benzonatate, and dextromethorphan. The side effects of codeine are nausea, drowsiness, lightheadedness, and constipation. Codeine has a boxed warning for potential respiratory depression and death in children receiving it after certain surgeries. Codeine is also thought to be associated with mucosal drying. Depending on its concentration, strength, and other medications it is combined with, codeine may be a Schedule 2, 3, or 5 drug. The combination product hydrocodone and chlorpheniramine has the following side effects: blurred vision, drowsiness, constipation, and mood changes. This combination has the potential for CNS and respiratory depression and should be used with caution in older adults. This drug has abuse potential and, therefore, is a Schedule 2 substance..

[Audio] Benzonatate is associated with the side effects of sedation, headache, and dizziness. There have also been reports of mental confusion and hallucinations with its use. Dextromethorphan is a nonopioid derivative of morphine and may be the most common nonopioid agent used for cough. If large quantities of dextromethorphan are consumed, it can produce hallucinations. For this reason, dextromethorphan has become a recreational drug, especially among teenagers. For states that regulate sales to minors, dextromethorphan purchasers must be 18 years of age or older and be able to show proof of age. Common side effects of dextromethorphan include nausea, vomiting, dizziness, and drowsiness..

[Audio] The expectorant guaifenesin decreases the thickness and viscosity of mucus. In doing so, guaifenesin is used to rid the lungs and airway of mucus when coughing. Guaifenesin is available in various oral formulations, and its main side effects are vomiting, nausea, GI upset, and drowsiness..

[Audio] Decongestants make breathing easier and allow sinus cavities to drain. Topical agents work faster than oral, but the duration of their effect is shorter. Decongestants should not be given to patients who cannot tolerate sympathetic nervous system stimulation. Sympathetic nervous stimulation increases heart rate, increases blood pressure, and heightens CNS stimulation. Often the decongestants are combined with antihistamines to offset the antihistamine side effect of drowsiness. Topical nasal application of these drugs over prolonged periods is often followed by rebound congestion. Patients with this condition use more spray more often, but it is less effective. Duration of therapy with a topical nasal decongestant should be limited to three to five days. Decongestants should be used with caution in older patients and in those with hypertension, diabetes, or cardiovascular disease..

[Audio] Pseudoephedrine and phenylephrine are the only two decongestants on the market that are available orally. Pseudoephedrine has a strong abuse potential and is used in methamphetamine production. For these reasons, it is kept behind the counter, requires identification for purchase, and limits have been placed on purchase quantities. Phenylephrine, on the other hand, has no special dispensing requirements and has replaced pseudoephedrine in many products. Both nasal and oral products are available for this medication..

[Audio] Pharmacy technicians should know the daily purchase limits of products containing pseudoephedrine. At the time of publication, there was a daily limit of 3.6 grams per customer, 7.5 grams per month per customer for mail order, and 9 grams per month per customer at retail stores..

[Audio] First-generation antihistamines for cold and allergy include chlorpheniramine, clemastine, and diphenhydramine. These agents block the histamine response and are all used for the common cold and allergies. In addition, diphenhydramine is used for sleep promotion, which is an example of a medication being prescribed for its side effects. The first-generation antihistamines may cause CNS depression. These drugs should be used with caution in older adults due to the increased risk of confusion, dry mouth, and constipation. Because of these side effects, these drugs are on the Beers Criteria of potentially inappropriate drugs for older adults..

[Audio] The second-generation antihistamines include cetirizine, fexofenadine, loratadine, desloratadine, azelastine, and olopatadine. These agents were developed to provide antihistamine therapy without the unwanted side effects of the first-generation drugs. Second-generation antihistamines typically have fewer CNS side effects and cause less sedation. Cetirizine, fexofenadine, loratadine, and desloratadine are available as oral dosage forms. Their side effect profile includes some drowsiness, fatigue, and dry mouth, and should be used with caution in renal and hepatic dysfunction. Azelastine and olopatadine are both available as nasal sprays while olopatadine is also available as an ophthalmic solution. Side effects associated with azelastine and olopatadine include drowsiness, headache, bitter taste, and nose bleeding. Blurred vision and eye irritation may occur with the use of olopatadine ophthalmic solution..

[Audio] Multiple nasal corticosteroids are available for the treatment of allergic rhinitis. They are now considered the most effective agents for monotherapy of allergic rhinitis. The medications in this class are primarily associated with local side effects such as cough, sore throat, runny nose, nasal irritation, and nasal bleeding..

[Audio] Nasal corticosteroids are administered intranasally. When using nasal corticosteroids, patients should follow these steps. Shake product well. Clear nasal passages by blowing the nose or using a saline irrigation system. Sit in an upright position with the head tilted slightly forward. Close one nostril by pressing it with a finger. Insert sprayer into the other nostril. Breathe in and depress the applicator to deliver a metered dose. Breathe out from the mouth. Repeat the procedure for the other nostril. There is no need to breathe in quickly or forcefully or to hold the breath..

[Audio] Chapter 11, Section 7, Tobacco Use, Smoking Cessation, and Corresponding Drug Treatments..

[Audio] The impact of cigarette smoking on the respiratory system is destructive, and results in damaged airways and alveoli. Smoking increases the risk for asthma, heart disease, stroke, cancer, type 2 diabetes mellitus, rheumatoid arthritis, reproductive difficulties, and decreased bone health. The physical benefits of not smoking include a longer life and better overall health..

[Audio] Nicotine is the addictive component of tobacco. Nicotine is absorbed into the lungs from inhaled smoke and across oral or nasal mucosa from smokeless tobacco products. Chronic nicotine ingestion leads to physical and psychological dependence. Consequently, quitting smoking results in withdrawal symptoms. Symptoms include anxiety, craving for tobacco, decreased blood pressure, decreased heart rate, depression, difficulty concentrating, drowsiness, frustration, irritability, impatience, restlessness, GI disturbances, headache, hostility, increased skin temperature, and insomnia..

[Audio] Smoking cessation treatment involves three main elements. These elements are behavior modification, social support from the clinician, and nicotine replacement therapy. Nicotine replacement therapy is recommended as first-line pharmacotherapy for smokers who do not have contraindications. However, patients must understand that nicotine replacement therapy is not a substitute for behavior modification, and that success is greatest when both are used simultaneously. The first step in establishing a plan for quitting smoking is setting a date. Next, inform family, friends, and coworkers of the decision and ask for their understanding and support. After gaining their support, remove all cigarettes from the environment and avoid spending a lot of time in places where smoking is prevalent. Next, if applicable, review previous attempts to quit and analyze the factors that caused relapse. Lastly, it is important to anticipate challenges, particularly during the critical first few weeks..

[Audio] Nicotine supplements are used to reduce absorbed nicotine slowly over time and to reduce withdrawal symptoms. These supplements are available as a gum, inhaler, lozenge, and patch. All nicotine supplements should be used with caution in heart disease, hypertension, and arrhythmias. Various cautions and considerations apply to particular dosage forms..

[Audio] In addition to nicotine supplements, bupropion and varenicline are available as options to aid in smoking cessation efforts. They are both available as tablets. Bupropion is an antidepressant used to combat mood changes and emotional instability associated with quitting smoking. Bupropion can also reduce nicotine cravings. Important considerations with the use of bupropion are to taper the dose when discontinuing and to report symptoms of depression or suicidal ideation. Bupropion carries a boxed warning for adverse mental health events. Patients should be observed for signs of agitation, hostility, depression, and changes in behavior. Varenicline is used to reduce the severity of cravings and withdrawal symptoms. Similar to bupropion, patients should be observed for depression symptoms, suicidal ideation, and adverse mental health events..

[Audio] Chapter 11, Section 8, Complementary and Alternative Therapies..

[Audio] A number of complementary and alternative therapies are used for the treatment of respiratory diseases. Boswellia serrata is a branching tree whose resin is used to treat chronic inflammatory diseases such as asthma. Boswellia serrata is consumed as the powdered form of the plant resin. Choline is related to B-vitamins and is used for chronic asthma. Yoga has been used to improve symptoms of mild to moderate asthma and COPD. Nasal irrigation may effectively relieve allergies and sinusitis. It is important to use clean irrigation dispensers and sterile water. Saline nasal spray is a salt-water nasal spray that can also be used to help relieve nasal congestion by helping to loosen secretions..