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Case Scenario of Robert

Discuss About The Pharmacologic Rationale Underlying Effects.

The report is concerned with the case scenario of Robert, a 51 year old man admitted to hospital for acute exacerbation of chronic obstructive pulmonary disease (COPD). COPD is a progressive lung disease associated with airflow obstruction and abnormal inflammatory response. Inflammatory response is seen due to exposure to noxious fumes like cigarette smoke and chemical fumes. The activation of T –lymphocyte, B cells and neutrophils leads to the initiation of an inflammatory cascade and many inflammatory mediators like fibrinogen, C reactive protein and interleukins are released. These inflammatory mediators play a major role in sustaining the inflammatory process and causing systemic changes and tissue damage (Brashier & Kodgule, 2012). Due to such structural changes, clinical presentation of airflow obstruction was also observed for Robert.

The two disease process contained in the umbrella term COPD is chronic bronchitis and emphysema or destruction of the lung parenchyma. The process leading to these two disease condition is understood from the pathogenesis of COPD explained above. The series of inflammatory process provoked by exposure to tobacco smoke results in chronic bronchitis and emphysema. T lymphocytes dominate in the bronchial mucosa of COPD patients (Barrett-Connor et al., 2011).

Robert had to stay in intensive care unit (ICU) for 3 days for an acute exacerbation of COPD. Acute exacerbation of COPD is the term given to the appearance of sudden worsening symptoms in CVD patients such as acute shortness of breath, increased sputum production and change in colour of sputum (Ko et al., 2016). This kind of increase in airway inflammation is seen mainly due to acute respiratory infection and exposure to allergens and toxins. Respiratory infections are mainly caused by bacterial pathogens like Streptococcus pneumoniae and viral pathogens like Mycoplasma pneumonia and Chymydia sp.  Many environmental stressors and noxious chemicals is also responsible for acute exacerbation of COPD. (Lin et al., 2016). This kind of infectious exacerbation was the reason for increased impairment of lung function and long duration of hospitalization for Robert.

Robert became at high risk for exacerbations of COPD mainly because of community acquired pneumonia and smoking habits. He became more prone to risk because of advancing age and history of hospitalization (Montserrat-Capdevila et al., 2016). Other factors contributing exacerbation of COPD symptoms include presence of cardiac dysfunction in patients. This acts as a trigger for respiratory decompensation in patient and becomes a reason for acute exacerbation of COPD (Lin et al., 2016).

Pharmacologic Rationale Underlying Effects of COPD

Pneumonia is a respiratory infection associated with inflammation of the alveoli of one or both lungs and manifestation of clinical symptoms like dry cough and difficulty in breathing occurs due to the exposure of lungs to pulmonary irritants. Loss of upper reflexes allows aspiration of pathogens into the upper airways of the lungs, which then reaches the lung parenchyma. The virulence of the organism leads to exaggerated immune response in the lungs and release of protein rich fluids into the alveoli. The accumulation of fluids impairs oxygen and carbon dioxide exchange and impairment in gas exchange becomes the cause of bacterial pneumonia (Arshad et al., 2016).

Pneumonia is classified into three types such as community Acquired, hospital Acquired and health care associated pneumonia (HCAP). Community acquired pneumonia (CAP) is a kind of pneumonia that occurs in people who have no contact with hospital setting or the health care system. Most common pathogen behind community acquired pneumonia includes Streptococcus pneumoniae, Haemophilus influenza and viruses (Singh, 2012). In contrast to CAP, hospital acquired pneumonia is a term given to the diagnosis of pneumonia in patient after 48 to 72 hours of hospital admission.  This type of pneumonia is mainly cause by bacterial pathogens like Staphylococcus aureus and antibiotic resistant bacteria and not virus. In addition, the third type, HCAP is different from other two types pneumonia in the fact that it occurs before admission to hospital in patient with recent hospitalization or those with weakened immune system (Kalil et al., 2016). Robert mainly had community acquired pneumonia which led to acute exacerbation of COPD.

Robert was taking Salbutamol, Budesonide/Efomoterol fumarate dehydrate, however the respiratory physician ordered Robert to use Tiotropium instead of Budesonide/Efomoterol fumarate dehydrate. The details about each of the three inhalers are as follows:

Mechanism of action in COPD: COPD is associated with inflammation of the lungs and hypersecretion of mucus. Salbutamol was prescribed to Robert as it is a beta (2)-adrenergic agonist, which bind to beta2 andrenergic receptors in airway smooth muscles and activates the Adenyl cyclise enzyme. This leads to increased production of cyclic AMP and reduction in the intracellular calcium concentration thus leading to smooth muscle relaxation (Neame et al., 2015). In this way, it reduces symptoms of breathlessness and whizziness in COPD patients.

Contraindication and adverse reactions: The contraindication of the drug includes hypersensitivity reactions to adrenergic amines. Some of the adverse reaction of Salbutamol includes muscle cramps, agitation, palpitation and certain psychotic reactions (Salbutamol.org, 2018). 

Pharmacologic Rationale Underlying Effects of Pneumonia

While providing Salbutamol to patient, nurse must assess for lung sounds and blood pressure before administration and during peak of medication. They should discontinue the drug of symptoms of paradoxical bronchospasm is found. Patient must be educated about taking the recommended dose of drug and notifying to physician in case of adverse side effects. Patient like Robert should also be educated about the correct way to  use the inhaler and maintaining a five minutes gap before taking another inhaler (Neininger et al., 2015).

Mechanism of action in COPD: This drug was given to Robert to reduce exacerbation of COPD. The drug consists of two active ingredients. One is Budesonide which is an anti – inflammatory corticosteroid that works to reduce inflammation in the respiratory tract and the other active component is the Efomoterol fumarate dehydrate, which is a long acting beta2 -agonist bronchodilator, that decreases airway resistance and improves airflow to the lungs (Wolthers, 2016).

Contraindication and adverse reactions: It is found to interact with other drugs like beta agonist and diuretics. Adverse reaction of the inhaler includes muscle cramps, blurred vision, tremors, increased urination and mood changes (Dailymed.nlm.nih.gov, 2018). 

Nursing consideration and patient education points: Once patients start using the drug as inhalers, nurse should always assess for lungs sounds, respiratory status and pulmonary function in patient. If the patient is using other kinds of inhalers, then nurse should educate patients regarding using the other inhalers in 5 minutes interval. Patient should also be strictly advised to avoid smoking during this period as this may minimize the therapeutic effect of the drug (Dailymed.nlm.nih.gov, 2018).

Mechanism of action in COPD: Tiotropium is a long acting anticholinergic drug that has specificity for muscarinic receptors M1 to M5. It renders therapeutic effect by inhibiting the M3 receptors at the smooth muscle. It reduces severity of bronchospasm and leads to bronchodilation (Pelaia et al., 2015). For this reason, it was prescribed to Robert.

Contraindication and adverse reactions: Tiotropium needs to be used cautiously in pregnant or lactating women due to hypersensitivity to milk proteins. Some of the adverse reactions of the drug include hypersensitivity reaction, worsening of glaucoma, problem in urinary retention and constipation (Hamelmann & Szefler, 2018).

Nursing consideration and patient education points: It is necessary for nurse to assess respiratory status of patients before administering the drug. This is necessary to observe for adverse signs like severe bronchospasm in patients. Education should also be given regarding ways to use the drug and immediately notifying to clinical when swelling of lip and throat itching is found after inhaling the drug (Lyseng-Williamson & Keating, 2015).

Drugs Used in COPD Treatment

The respiratory physician might have changed Robert’s medication regime because of observation of side effects like that of worsening asthma symptom and wheeziness in patient. The advantage of tiotropium over Budesonide/Efomoterol fumarate dehydrate is that it works to reduces acute exacerbation in COPD patient and has long terms benefits in preventing hospitalization in patients too (Buhl et al., 2017).

Robert was diagnosed with CAP and it was found that Streptococcus pneumonia was the main pathogen behind CAP. Three antibiotics that can be given to Robert to treat Streptococcus pneumoniae include the following:

Mechanism of action: Ceftriaxone is an antibiotic mainly given for treatment of pneumococcal infection caused by S. Pneumoniae. The therapeutic action of the drug is seen due to its role in inhibiting the synthesis of bacterial cell wall by binding to the transpeptidase. This kind of inhibition leads to the damage of bacterial cell wall and ultimately cell death (Pubchem.ncbi.nlm.nih.gov, 2018). .

Contraindication and adverse reactions: Ceftriaxone shows hypersensitivity to cephalosporin and penicillin. Seizure, diaarhea, rashes and haemolytic anemia are some adverse reactions associated with the drug (Pubchem.ncbi.nlm.nih.gov, 2018).   

Nursing consideration and patient education: Throughout the antibiotic therapy, nurse must assess patients for signs of infection by means of vital sign assessment, sputum check and trackings changes in WBC. While continuing the therapy, signs of adverse reactions and symptoms of anaphylaxis must also be checked by nurses (Kizior et al., 2018).

Mechanism of action: Rifampin acts to inhibit the action of RNA polymerase and preventing RNA synthesis thus prevention the development of bacterial proteins. This kind of bactericidal action prevents infections caused by Streptococcus pneumoniae (Vallerand, Sanoski & Deglin, 2016). .

Contraindication and adverse reactions: The drug should be used with precaution when patient is taking drugs like atazanavir, tipranavir or saquinavir. Fatigue, diarhhea, abdominal pain and haemolytic anaemia are some adverse reactions of the drug.

Nursing consideration and patient education: During the therapy, susceptibility test should be done to identify resistance. Nurse should also assess lung sounds and characteristics of sputum and observe for side effects of the drug in patient. Patient education is mainly required in the area of notifying patients about the side effects and reporting about it as soon as possible (Kee, Hayes & McCuistion, 2014).

Mechanism of action: Vancomycin acts against gram positive bacteria and prevent biosynthesis of bacterial cell wall by binding to the N-acetylmuramic acid and N-acetylglucosamine of the peptidoglycan. This weakens the peptidoglycan layer and more permeable resulting in leakage of the cell content and ultimately bacterial death (Satoskar, Rege & Bhandarkar, 2015).

Antibiotics for Pneumonia Treatment

Contraindication and adverse reactions: The use of vancomycin is associated with side effects like rashes, hypersensitivity, nausea, back and neck pain. The drug should be used with precaution in elderly patients, patients with renal impairment and those with intestinal obstruction.

Nursing consideration and patient education: While giving vancomycin to Robert, nurse must assess him for sign of infection before and during the therapy. Nurse should monitor IV site closely as the drug act as irritant for tissues and leads to tissue necrosis. They also have a role in educating patients about serious adverse reactions and reporting about those signs to patient.

The first evidence based intervention for the management of Robert’s COPD is the use of oxygen therapy. Research evidence proves that long terms use of supplemental oxygen can effectively treat symptoms of severe resting hypoxemia and breathlessness in patient and increase quality of life of patients too (McDonald, 2014). The second intervention to support Robert to effectively cope with COPD symptom is to provide self management education to Robert so that he can monitor symptoms himself and take necessary precaution to prevent emergency admission to the hospital (Hardinge et al., 2015). Apart from self management education, the third intervention that is important for Robert is implementing smoking cessation intervention. Robert has a history of smoking and since smoking deteriorate condition of COPD patient, smoking cessation intervention like nicotine replacement therapy is necessary to minimize complex in patient (Safka  & McIvor, 2015).

Reference:

Arshad, H., Fasanya, A., Cheema, T., & Singh, A. C. (2016). Acute pneumonia. Critical care nursing quarterly, 39(2), 148-160, doi: 10.1097/CNQ.0000000000000108

Barrett-Connor, E., Ayanian, J. Z., Brown, E. R., Coultas, D. B., Francis, C. K., Goldberg, R. J., ... & Mannino, D. M. (2011). A Nationwide Framework for Surveillance of Cardiovascular and Chronic Lung Diseases. Washington DC, USA, Available at: https://www.nationalacademies.org/hmd/Reports/2011/A-Nationwide-Framework-for-Surveillance-of-Cardiovascular-and-Chronic-Lung-Diseases.aspx

Brashier, B. B., & Kodgule, R. (2012). Risk factors and pathophysiology of chronic obstructive pulmonary disease (COPD). J Assoc Physicians India, 60(Suppl), 17-21, Available at: https://pdfs.semanticscholar.org/517c/439f8badef329dc35d5569d433e550470bf2.pdf

Buhl, R., McGarvey, L., Korn, S., Ferguson, G. T., Grönke, L., Hallmann, C., ... & Maltais, F. (2017). Benefits of Tiotropium+ Olodaterol Over Tiotropium at Delaying Clinically Significant Events in Patients with COPD Classified as GOLD B. Pneumologie, 71(S 01), P240, Available at: https://www.atsjournals.org/doi/pdf/10.1164/ajrccm-conference.2016.193.1_MeetingAbstracts.A6779

Dailymed.nlm.nih.gov. (2018).  DailyMed - SYMBICORT- budesonide and formoterol fumarate dihydrate aerosol.  Retrieved 4 March 2018, from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=fafa4cf1-99c2-43d5-73ad-51f256de3be0

Hamelmann, E., & Szefler, S. J. (2018). Efficacy and Safety of Tiotropium in Children and Adolescents. Drugs, 1-12, Available at: https://link.springer.com/article/10.1007/s40265-018-0862-1

Conclusion

Hardinge, M., Rutter, H., Velardo, C., Shah, S. A., Williams, V., Tarassenko, L., & Farmer, A. (2015). Using a mobile health application to support self-management in chronic obstructive pulmonary disease: a six-month cohort study. BMC medical informatics and decision making, 15(1), 46, doi: https://doi.org/10.1186/s12911-015-0171-5

Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J., Sweeney, D. A., Palmer, L. B., ... & El Solh, A. A. (2016). Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clinical Infectious Diseases, 63(5), e61-e111, Doi:  10.1093/cid/ciw353

Kee, J. L., Hayes, E. R., & McCuistion, L. E. (2014). Pharmacology-E-Book: A Patient-Centered Nursing Process Approach. Elsevier Health Sciences, Available at: https://books.google.co.in/books?hl=en&lr=&id=abnwAwAAQBAJ&oi=fnd&pg=PP1&dq=Pharmacology-E-Book:+A+Patient-Centered+Nursing+Process+Approach.&ots=pHeNn63UoX&sig=PrSEQiT_uee8nYnDGhJs9rGAGAc#v=onepage&q=Pharmacology-E-Book%3A%20A%20Patient-Centered%20Nursing%20Process%20Approach.&f=false

Kizior, R. J., Rph, B., Hodgson, B. B., & Ocn, R. N. (2018). Saunders Nursing Drug Handbook 2019 E-Book. Elsevier Health Sciences, Available at: https://books.google.co.in/books?hl=en&lr=&id=eJNNDwAAQBAJ&oi=fnd&pg=PP1&dq=Saunders+Nursing+Drug+Handbook+2019+E-Book.&ots=6LlvOz8zez&sig=i8YMfYdscCCtEczi5f-paaSWeKw#v=onepage&q=Saunders%20Nursing%20Drug%20Handbook%202019%20E-Book.&f=false

Ko, F. W., Chan, K. P., Hui, D. S., Goddard, J. R., Shaw, J. G., Reid, D. W., & Yang, I. A. (2016). Acute exacerbation of COPD. Respirology, 21(7), 1152-1165, Doi: 10.1111/resp.12780

Lin, S. H., Perng, D. W., Chen, C. P., Chai, W. H., Yeh, C. S., Kor, C. T., ... & Lin, C. H. (2016). Increased risk of community-acquired pneumonia in COPD patients with comorbid cardiovascular disease. International journal of chronic obstructive pulmonary disease, 11, 3051, doi:  10.2147/COPD.S115137

Lyseng-Williamson, K. A., & Keating, G. M. (2015). Tiotropium Respimat® Soft Mist™ inhaler: a guide to its use in chronic obstructive pulmonary disease (COPD) in the EU. Drugs & Therapy Perspectives, 31(2), 39-44, DOI 10.1007/s40267-014-0181-x

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McDonald, C. F. (2014). Oxygen therapy for COPD. Journal of thoracic disease, 6(11), 1632, doi:  10.3978/j.issn.2072-1439.2014.10.23

Montserrat-Capdevila, J., Godoy, P., Marsal, J. R., Barbé, F., & Galván, L. (2016). Risk factors for exacerbation in chronic obstructive pulmonary disease: a prospective study. The International Journal of Tuberculosis and Lung Disease, 20(3), 389-395, DOI: https://doi.org/10.5588/ijtld.15.0441

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Pelaia, G., Vatrella, A., Busceti, M. T., Gallelli, L., Calabrese, C., Terracciano, R., ... & Maselli, R. (2015). Pharmacologic rationale underlying the therapeutic effects of tiotropium/olodaterol in COPD. Therapeutics and clinical risk management, 11, 1563, Doi: 10.2147/TCRM.S84151

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Safka, K. A., & McIvor, R. A. (2015). Non-pharmacological management of chronic obstructive pulmonary disease. The Ulster medical journal, 84(1), 13, Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4330800/

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Wolthers, O. D. (2016). Budesonide+ formoterol fumarate dihydrate for the treatment of asthma. Expert opinion on pharmacotherapy, 17(7), 1023-1030, DOI: 10.1517/14656566.2016.1165207

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