Rau's Respiratory Care Pharmacology

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Contributors
Preface
Acknowledgments
Contents
Unit A - Basic Concepts and Principles in Pharmacology
	1 - Introduction to Respiratory Care Pharmacology
		Pharmacology and the Study of Drugs
		Naming Drugs
		Sources of Drug Information
		Sources of Drugs
		Process for Drug Approval in the United States
			Chemical Isolation and Identification
			Animal Studies
			Investigational New Drug Approval
				Phase 1
				Phase 2
				Phase 3
			New Drug Application
			FDA New Drug Classification System
			Orphan Drugs
		The Prescription
			Over-the-Counter Drugs
			Generic Substitution in Prescriptions
		Respiratory Care Pharmacology: An Overview
			Aerosolized Agents Given by Inhalation
			Related Drug Groups in Respiratory Care
		References
	2 - Principles of Drug Action
		Drug Administration Phase
			Drug Dosage Forms
				Drug Formulations and Additives
			Routes of Administration
				Enteral
				Parenteral (Injectable)
				Transdermal
				Inhalation
				Topical
		Pharmacokinetic Phase
			Absorption
				Aqueous Diffusion
				Lipid Diffusion
				Carrier-Mediated Transport
				Pinocytosis
				Factors Affecting Absorption
			Distribution
				Volume of Distribution
			Metabolism
				Site of Drug Biotransformation
				Enzyme Induction and Inhibition
				First-Pass Effect
			Elimination
				Plasma Clearance
				Maintenance Dose
				Plasma Half-Life
				Time–Plasma Curves
			Pharmacokinetics of Inhaled Aerosol Drugs
				Local Versus Systemic Effect
				Inhaled Aerosols in Pulmonary Disease
				Distribution of Inhaled Aerosols
					Oral Portion (Stomach)
					Inhaled Portion
				Lung Availability/Total Systemic Availability Ratio
		Pharmacodynamic Phase
			Structure–Activity Relationships
			Nature and Type of Drug Receptors
				Drug Receptors
				Lipid-Soluble Drugs and Intracellular Receptor Activation
				Drug-Regulated Ion Channels
				Receptors Linked to G Proteins
			Dose–Response Relationships
				Potency Versus Maximal Effect
				Therapeutic Index
				Agonists and Antagonists
				Drug Interactions
				Terms for Drug Responsiveness
		Pharmacogenetics
		References
	3 - Administration of Aerosolized Agents
		Physical Principles of Inhaled Aerosol Drugs
			Aerosol Particle Size Distributions
			Measurement of Particle Size Distributions
			Particle Size and Lung Deposition
				Fine Particle Fraction
				Particle Size and Therapeutic Effect
					Particles greater than 10 µm
					Particles 5 to 10 µm
					Particles 2 to 5 µm
					Particles 0.8 to 3.0 µm
				Mechanisms of Deposition
					Inertial Impaction
					Gravitational Settling
					Diffusion (Brownian Motion)
				Effect of Temperature and Humidity
		Aerosol Generators for Drug Delivery
			Nebulizers
				Types of Small Volume Nebulizers
					Jet (Pneumatic) Nebulizers
					Jet Nebulizer With Reservoir Tube
					Jet Nebulizer With Collection Bag or Elastomeric Ball
					Breath-Enhanced Jet Nebulizer
					Breath-Actuated Jet Nebulizer
					Manual Breath-Actuated Jet Nebulizer
					Mechanical Breath-Actuated Jet Nebulizer
					Mesh Nebulizers
					Active Vibrating Mesh Nebulizer
					Passive Mesh Nebulizer
					Ultrasonic Nebulizers
					Factors Affecting Jet Nebulizer Performance
					Dead Volume (Residual Volume)
					Filling Volume and Treatment Time
					Effect of Flow Rate and Pressure
					Type of Power Gas
					Device Interface
					Type of Solution
			Pressurized Metered Dose Inhalers
				Technical Description
				Chlorofluorocarbon Versus Hydrofluoroalkane Propellants
					Equivalence and Safety
					Improved Drug Delivery With Hydrofluoroalkane Formulation
				Types of Pressurized Metered Dose Inhalers
					Conventional Pressurized Metered Dose Inhaler
					Breath-Actuated Pressurized Metered Dose Inhaler
					Respimat Soft Mist Inhaler
					Breath-Actuated Pressurized Metered Dose Inhaler Accessory Devices
				Factors Affecting Metered Dose Inhaler Performance
					Loss of Dose
					Shaking the Canister
					Timing of Actuation Intervals
					Loss of Prime
					Storage Temperature
					Nozzle Size and Cleanliness
					Breathing Technique
					Patient Characteristics
				Correct Use of a Pressurized Metered Dose Inhaler
				Accessory Devices for Pressurized Metered Dose Inhalers
					Types of Pressurized Metered Dose Inhaler Accessory Devices
					Design Variables
					Electrostatic Charge
					Size
					Dose Counters
			Dry Powder Inhalers
				Types of Dry Powder Inhalers
					Unit-Dose Dry Powder Inhalers
					Multiple Unit–Dose Dry Powder Inhalers
					Multiple-Dose Dry Powder Inhalers
				Factors Affecting Dry Powder Inhaler Performance and Drug Delivery
					Intrinsic Resistance
					Inspiratory Flow Rate
					Humidity
					Clinical Efficacy
		Selecting an Aerosol Device
		Clinical Application of Aerosol Delivery Devices
			Recommendations Based on Clinical Evidence
				Aerosol Delivery of Short-Acting β2 Agonists in the Emergency Department
				Aerosol Delivery of Short-Acting β2 Agonists in the Hospital
				Intermittent Versus Continuous Nebulizer Delivery of β2 Agonists
				Aerosol Delivery of β2 Agonists to Patients Receiving Mechanical Ventilation
				Aerosol Delivery of Short-Acting β2 Agonists for Asthma in the Outpatient Setting
				Delivery of Inhaled Corticosteroids for Asthma
				Delivery of β2 Agonists and Anticholinergic Agents for Chronic Obstructive Pulmonary Disease
				Factors to Consider
			Lung Deposition and Loss Patterns With Traditional Aerosol Devices
			Equivalent Doses Among Device Types
			Lung Deposition With Newer Aerosol Devices
			Clinical Equivalence of Metered Dose Inhalers and Nebulizers
			Age Guidelines for Use of Aerosol Devices
			Patient–Device Interface
				Administration by Intermittent Positive-Pressure Breathing
				Face Mask and Blow-by Administration
				Mechanical Ventilation Administration
				Adjunct Systems for Aerosol Therapy
				Technological Adjuncts for Aerosol Therapy
			Recommendations for the COVID-19 Pandemic
		References
	4 - Calculating Drug Doses
		Systems of Measure
			Metric System
			International System of Units
			Household Units of Measure
		Calculating Doses From Prepared-Strength Solutions
			Calculating With Proportions
		Answer
		Answer
			Drug Amounts in Units
		Answer
			Calculations With a Dosage Schedule
		Answer
			Additional Examples: Prepared-Strength Drugs
		Answer
		Answer
		Answer
		Answer
		Calculating Doses From Percent-Strength Solutions
			Types of Percent Preparations
				Weight to Weight
				Weight to Volume
				Volume to Volume
			Solutions by Ratio
				Ratio by Grams to Milliliters
				Ratio by Simple Parts
			Solving Percent-Strength Solution Problems
		Answer
		Answer
		Summary
			Quantity Sufficient
			Percent Strengths in Milligrams per Milliliter
			Diluents and Drug Doses
			Additional Examples: Solutions
		Answer
		Answer
		Answer
		Answer
		Answer
		Reference
	5 - Central and Peripheral Nervous Systems
		Nervous System
		Autonomic Branches
			Parasympathetic and Sympathetic Regulation
			Neurotransmitters
			Efferent and Afferent Nerve Fibers
			Terminology of Drugs Affecting the Nervous System
		Parasympathetic Branch
			Cholinergic Neurotransmitter Function
			Muscarinic and Nicotinic Receptors and Effects
				Muscarinic Effects
				Nicotinic Effects
			Subtypes of Muscarinic Receptors
		Cholinergic Agents
			Direct-Acting Cholinergic Agents
			Indirect-Acting Cholinergic Agents
				Cholinesterase Reactivator (Pralidoxime)
		Anticholinergic Agents
			Atropine as a Prototype Parasympatholytic Agent
			Parasympatholytic (Antimuscarinic) Effects
		Sympathetic Branch
			Adrenergic Neurotransmitter Function
			Enzyme Inactivation
			Sympathetic (Adrenergic) Receptor Types
				α and β Receptors
				β1 and β2 Receptors
				α1 and α2 Receptors
				Dopaminergic Receptors
		Sympathomimetic (Adrenergic) and Sympatholytic (Antiadrenergic) Agents
		Neural Control of Lung Function
			Sympathetic Innervation and Effects
				Airway Smooth Muscle
				β Receptors.
					α Receptors
				Lung Blood Vessels
				Mucous Glands
			Parasympathetic Innervation and Effects
				Muscarinic Receptors in the Airway
					M1 Receptors
					M2 Receptors
					M3 Receptors
				Muscarinic Receptors on Blood Vessels
			Nonadrenergic, Noncholinergic Inhibitory Nerves
			Nonadrenergic, Noncholinergic Excitatory Nerves
		References
Unit B
Drugs Used to Treat the Respiratory System
	6 - Adrenergic (Sympathomimetic) Bronchodilators
		Clinical Indications for Adrenergic Bronchodilators
			Indication for Short-Acting Agents
			Indication for Long-Acting Agents
			Indication for Racemic Epinephrine
		Specific Adrenergic Agents and Formulations
			Catecholamines
				Adrenergic Bronchodilators as Stereoisomers
					Epinephrine
				Keyhole Theory of β2 Specificity
				Metabolism of Catecholamines
			Resorcinol Agents
			Saligenin Agents
		Levalbuterol: (R)-Isomer of Albuterol
		Long-Acting β-Adrenergic Agents
			Extended-Release Albuterol
				Salmeterol
					Bronchodilator Effect
				Formoterol
					Bronchodilator Effect
					Arformoterol
					Indacaterol
					Olodaterol
					Vilanterol
					Antiinflammatory Effects
					Clinical Use
		Mechanism of Action
			β-Receptor and α2-Receptor Activation
			α1-Receptor Activation
		Long-Acting β Agonists: Mechanism of Action
		Routes of Administration
			Inhalation Route
				Continuous Nebulization
					Delivery Methods
					Toxicity and Monitoring
		Oral Route
		Parenteral Route
		Adverse Side Effects
			Tremor
			Cardiac Effects
			Tolerance to Bronchodilator Effect
			Loss of Bronchoprotection
			Central Nervous System Effects
			Fall in Arterial Oxygen Pressure
			Metabolic Disturbances
			Propellant Toxicity and Paradoxical Bronchospasm
			Sensitivity to Additives
		Compatibility of Other Agents With Bronchodilators
		β-Agonist Controversy
			Asthma Morbidity and Mortality
		Respiratory Care Assessment of β-Agonist Therapy
			Before Treatment
			During Treatment and Short Term
			Long Term
				For Long-Acting β Agonists
			General Contraindications
		References
	7 - Anticholinergic (Parasympatholytic) Bronchodilators
		Clinical Indications for Use
			Indication for Anticholinergic Bronchodilators
			Indication for Combined Anticholinergic and β-Agonist Bronchodilators
			Anticholinergic Nasal Spray
		Specific Anticholinergic (Parasympatholytic) Agents
		Clinical Pharmacology
			Structure–Activity Relationships
			Pharmacologic Effects of Anticholinergic (Muscarinic Antagonist) Agents
				Tertiary Ammonium Compounds
					Respiratory Tract Effects
					Central Nervous System Effects
					Eye Effects
					Cardiac Effects
					Gastrointestinal Effects
					Genitourinary Effects
				Quaternary Ammonium Compounds
					Respiratory Tract Effects
					Central Nervous System Effects
					Eye Effects
					Cardiac Effects
					Gastrointestinal Effects
					Genitourinary Effects
		Mechanism of Action
			Vagally Mediated Reflex Bronchoconstriction
			Muscarinic Receptor Subtypes
		Adverse Effects
		Clinical Application
			Use in Chronic Obstructive Pulmonary Disease
			Use in Asthma
			Combination Therapy: β-Adrenergic and Anticholinergic Agents in Chronic Obstructive Pulmonary Disease
				Additive Effect of β Agonists and Anticholinergic Agents
				Sequence of Administration
		Respiratory Care Assessment of Anticholinergic Bronchodilator Therapy
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		References
	8 - Xanthines
		Clinical Indications for the Use of Xanthines
			Use in Asthma
			Use in Chronic Obstructive Pulmonary Disease
			Use in Apnea of Prematurity
		Specific Xanthine Agents
		General Pharmacologic Properties
			Structure–Activity Relationships
			Proposed Theories of Activity
				Inhibition of Phosphodiesterase
				Antagonism of Adenosine
				Catecholamine Release
		Titrating Theophylline Doses
			Serum Levels of Theophylline
			Dosage Schedules
			Theophylline Toxicity and Side Effects
			Factors Affecting Theophylline Activity
			Clinical Uses of Theophylline
				Use in Asthma
				Use in Chronic Obstructive Pulmonary Disease
			Nonbronchodilating Effects of Theophylline
				Respiratory Muscle Strength
				Respiratory Muscle Endurance
				Central Ventilatory Drive
				Cardiovascular Effects
				Antiinflammatory Effects
			Use in Apnea of Prematurity
		Respiratory Care Assessment of Xanthines
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		References
	9 - Mucus-Controlling Drug Therapy
		Drug Control of Mucus: A Perspective
			Clinical Indication for Use
			Classification of Mucoactive Medications
		Physiology of the Mucociliary System
			Source of Airway Secretions
			Terminology: Mucus, Phlegm, and Sputum
			Surface Epithelial Cells
			Submucosal Mucous Glands
			Ciliary System
			Factors Affecting Mucociliary Transport
			Food Intake and Mucus Production
			Secretory Hyperresponsiveness and Mucus Hypersecretion
		Nature of Mucus Secretion
			Structure and Composition of Mucus
			Epithelial Ion and Water Transport
			Secretions in Disease States
				Chronic Bronchitis
				Asthma
				Bronchorrhea
				Plastic Bronchitis
				Cystic Fibrosis
		Physical Properties of Mucus
			Surface Forces
			Viscoelasticity and Cohesivity
				Rheology or Viscoelasticity
				Mucus as a Viscoelastic Material
				Spinnability (Cohesivity) of Mucus
			Non-Newtonian Nature of Mucus
		Mucoactive Agents
			Mucolysis and Mucociliary Clearance
		Mucolytics and Expectorants
			N-Acetyl-l-Cysteine and Other Thiol Mucolytics
				Indications for Use
				Mode of Action
				Hazards
				Incompatibility With Antibiotics in Mixture
			Dornase alfa (Pulmozyme)
				Indication and Use in Cystic Fibrosis
				Mode of Action
				Dose and Administration
				Adverse Effects
				Clinical Application and Evaluation
			Filamentous Actin-Depolymerizing Drugs: Thymosin β4
			Expectorants
				Iodide-Containing Agents
				Sodium Bicarbonate
				Guaifenesin (glycerol guiacolate)
				Dissociating Solvents
				Oligosaccharides
		Mucokinetic Agents
			Bronchodilators
			Surface-Active Phospholipids
		Mucoregulatory Medications
		Other Mucoactive Agents
			Antiproteases
			Hyperosmolar Saline and Mannitol
		Gene Therapy
		Using Mucoactive Therapy With Physiotherapy and Airway Clearance Devices
			Insufflation-Exsufflation; Cough Assist
			Active Cycle of Breathing and Forced Expiratory Technique Maneuver
			Autogenic Drainage
			Exercise
			Positive Airway Pressure
			High-Frequency Chest Wall Compression
			Oscillatory Positive Expiratory Pressure
			Chest Wall Compression
		Future Mucus-Controlling Agents
		Respiratory Care Assessment of Mucoactive Drug Therapy
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		References
	10 - Surfactant Agents
		Physical Principles
			Surfactant
			Surface Tension
			Laplace’s Law
				Application to the Lung
		Clinical Indications for Exogenous Surfactants
		Identification of Surfactant Preparations
			Composition of Pulmonary Surfactant
				Lipids
				Proteins
				Surfactant Protein A (SP-A)
				Surfactant Proteins B and C (SP-B and SP-C)
				Surfactant Protein D (SP-D)
			Production and Regulation of Surfactant Secretion
			Types of Exogenous Surfactant Preparations
				Natural and Modified Natural Surfactant
				Synthetic Surfactant
				Synthetic Natural Surfactant
		Specific Exogenous Surfactant Preparations
			Beractant (Survanta)
				Indications for Use
				Dosage
				Administration
			Calfactant (Infasurf)
				Indications for Use
				Dosage
				Administration
					Side-Port Adapter
					Catheter Administration
			Poractant Alfa (Curosurf)
				Indications for Use
				Dosage
				Administration
			Lucinactant (Aerosurf)
		Hazards and Complications of Surfactant Therapy
			Airway Occlusion, Desaturation, and Bradycardia
			High Arterial Oxygen Values
			Overventilation and Hypocapnia
			Apnea
			Pulmonary Hemorrhage
		Future Directions in Surfactant Therapy
		Respiratory Care Assessment of Surfactant Therapy
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		References
	11 - Corticosteroids in Respiratory Care
		Clinical Indications for Use of Inhaled Corticosteroids
		Identification of Aerosolized Corticosteroids
		Physiology of Corticosteroids
			Identification and Source
			Hypothalamic–Pituitary–Adrenal Axis
			Hypothalamic–Pituitary–Adrenal Suppression With Steroid Use
			Diurnal Steroid Cycle
			Alternate-Day Steroid Therapy
		Nature of Inflammatory Response
			Inflammation in the Airway
		Aerosolized Corticosteroids
			Aerosolized Corticosteroid Agents
				Beclomethasone Dipropionate (Qvar RediHaler)
				Fluticasone Propionate (Flovent HFA, Flovent Diskus, and ArmonAir Respiclick/Digiclick)
				Fluticasone Furoate (Arnuity Ellipta)
				Budesonide (Pulmicort Flexhaler, Pulmicort Respules)
				Mometasone Furoate (Asmanex Twisthaler, Asmanex HFA)
				Ciclesonide (Alvesco)
				Albuterol/Budesonide (AIRSUPRA)
				Fluticasone Propionate/Salmeterol (AdvairDiskus, Advair HFA, Wixela Inhub AirDuo Respiclick/Digiclick)
				Mometasone Furoate/Formoterol (Dulera)
				Budesonide/Formoterol (Symbicort, Breyna)
				Fluticasone Furoate/Vilanterol (Breo Ellipta)
				Fluticasone Furoate/Umeclidinium/Vilanterol (Trelegy Ellipta)
					Budesonide/Glycopyrrolate/Formoterol (Breztri Aerosphere)
			Intranasal Corticosteroids
		Pharmacology of Corticosteroids
			Mechanism of Action
			Effect on White Blood Cell Count
			Effect on β Receptors
		Hazards and Side Effects of Steroids
			Systemic Administration of Steroids
			Systemic Side Effects With Aerosol Administration
			Topical (Local) Side Effects With Aerosol Administration
				Oropharyngeal Fungal Infections
				Dysphonia
				Other Complications or Precautions
		Clinical Application of Aerosol Steroids
			Use in Asthma
				Early Use of Corticosteroids in Asthma
				Inhaled Corticosteroids for Acute Severe Asthma
				Clinical Use of Inhaled Corticosteroids
				Use in Chronic Obstructive Pulmonary Disease
		Respiratory Care Assessment of Inhaled Corticosteroid Therapy
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		References
	12 - Nonsteroidal Antiasthma Agents
		Clinical Indications for Nonsteroidal Antiasthma Agents
		Identification of Nonsteroidal Antiasthma Agents
		Mechanisms of Inflammation in Asthma
			Immunologic (Allergic) Response
		Cromolyn-Like (Mast Cell–Stabilizing) Agents
			Cromolyn Sodium (Disodium Cromoglycate)
				Dosage and Administration
					Solution for Nebulization
					Metered Dose Inhaler
					Nasal Solution (NasalCrom)
				Mechanism of Action
				Pharmacokinetics
				Clinical Efficacy of Cromolyn Sodium
					Use for Cough Associated With Angiotensin-Converting Enzyme Inhibitor
					Anti–Sickle Cell Effects
				Clinical Application of Cromolyn Sodium
					Dosage Regulation
		Antileukotriene Agents
			Leukotrienes and Inflammation
				Cell Sources of Leukotrienes
				Biochemical Pathways
				Leukotriene Production
				Cysteinyl Leukotriene Receptors and Effects of Leukotrienes
			Zileuton (Zyflo)
				Dosage and Administration
				Mechanism of Action
				Pharmacokinetics
				Hazards and Side Effects
			Zafirlukast (Accolate)
				Dosage and Administration
				Mechanism of Action
				Pharmacokinetics
				Hazards and Side Effects
			Montelukast (Singulair)
				Dosage and Administration
				Mechanism of Action
				Pharmacokinetics
				Hazards and Side Effects
			Role of Antileukotriene Drugs in Asthma Management
				Protection Against Specific Asthma Triggers
				Chronic Persistent Asthma
				Antileukotrienes in Relation to Corticosteroids
				Churg-Strauss Syndrome
				Summary of Clinical Use of Antileukotriene Therapy
			Monoclonal Antibodies
				Dosage and Administration
				Mechanism of Action
				Hazards and Side Effects
				Summary of Clinical Use of Monoclonal Antibodies
		Respiratory Care Assessment of Nonsteroidal Antiasthma Agents
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		References
	13 - Aerosolized Antiinfective Agents
		Clinical Indications for Aerosolized Antiinfective Agents
			Indication for Aerosolized Pentamidine
			Indication for Aerosolized Ribavirin
			Indication for Aerosolized Tobramycin
			Indication for Aerosolized Aztreonam
			Indication for Inhaled Zanamivir
		Identification of Aerosolized Antiinfective Agents
			Aerosolized Pentamidine (NebuPent)
				Introduction of Aerosolized Pentamidine
				Rationale for Aerosol Administration
				Description of Pneumocystis Pneumonia
				Dosage and Administration
					Dosage
					Administration
					Nebulizer Performance
				Mechanism of Action
				Side Effects
					Side Effects With Parenteral Pentamidine
					Side Effects With Aerosol Administration
					Preventing Airway Effects
				Environmental Contamination by Nebulized Pentamidine
					Environmental Precautions
				Aerosol Therapy for Prophylaxis of Pneumocystis Pneumonia: Clinical Application
			Ribavirin (Virazole)
				Clinical Use
				Nature of Viral Infection
					Respiratory Syncytial Virus Infection
				Dosage and Administration
					Dosage
					Administration
				Mechanism of Action
				Side Effects
				Environmental Contamination With Aerosolized Ribavirin
			Palivizumab (Synagis)
				Clinical Use
				Dosage and Administration
				Mechanism of Action
				Adverse Reactions
				Clinical Efficacy
			Aerosolized Tobramycin (TOBI; Bethkis; Kitabis Pak)
				Clinical Use
				Dosage and Administration
				Mechanism of Action
				Side Effects
					Side Effects With Parenteral Administration
					Ototoxicity
					Nephrotoxicity
					Neuromuscular Blockade
					Cross-Allergenicity
					Fetal Harm
					Side Effects With Aerosolized Tobramycin
				Precautions in Use of Aerosolized Tobramycin
				Clinical Efficacy
			Aerosolized Aztreonam (Cayston)
				Clinical Use
				Dosage and Administration
				Mechanism of Action
				Precautions in Use of Nebulized Aztreonam
				General Considerations in Aerosolizing Antibiotics
			Inhaled Zanamivir (Relenza)
				Clinical Use
				Dosage and Administration
				Mechanism of Action
				Adverse Effects
					Bronchospasm and Deterioration of Lung Function
					Undertreatment of Bacterial Infection
					Allergic Reactions
					Other Adverse Effects
				Clinical Efficacy and Safety
		Respiratory Care Assessment of Aerosolized Antiinfective Agents
			Before Treatment
			During Treatment and Short Term
				Pentamidine
				Ribavirin
				Tobramycin
				Aztreonam
				Zanamivir
			Long Term
			General Contraindications
				Pentamidine
				Ribavirin
				Tobramycin
				Aztreonam
				Zanamivir
		References
	14 - Antimicrobial Agents
		Principles of Antimicrobial Therapy
		Identification of Pathogen
		Susceptibility Testing and Resistance
		Host Factors
		Pharmacodynamics
		Antimicrobial Combinations
		Monitoring Response to Therapy
		Antibiotics
			Penicillins
				Mechanism of Action
				Clinical Uses
					Natural Penicillins
					Penicillinase-Resistant Penicillins
					Aminopenicillins
					Carboxypenicillins
					Ureidopenicillins
					β-Lactam and β-Lactamase Inhibitor Combinations
				Adverse Reactions and Precautions
			Cephalosporins
				Mechanism of Action
				Clinical Uses
					First-Generation Cephalosporins
					Second-Generation Cephalosporins
					Third-Generation Cephalosporins
					Fourth-Generation Cephalosporins
					Fifth-Generation Cephalosporins
				Adverse Reactions and Precautions
			Carbapenems
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Monobactams (Aztreonam)
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Aminoglycosides
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Tetracyclines
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Tetracycline Derivatives
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Macrolides, Azalides, and Ketolides
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Fluoroquinolones
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Other Antibiotics
				Chloramphenicol
					Mechanism of Action
					Clinical Uses
					Adverse Reactions and Precautions
				Colistin (Colistimethate)
					Mechanism of Action
					Clinical Uses
					Adverse Reactions and Precautions
				Daptomycin
					Mechanism of Action
					Clinical Uses
					Adverse Reactions and Precautions
				Trimethoprim-Sulfamethoxazole
					Mechanism of Action
					Clinical Uses
					Adverse Reactions and Precautions
				Clindamycin
					Mechanism of Action
					Clinical Uses
					Adverse Reactions and Precautions
				Metronidazole
					Mechanism of Action
					Clinical Uses
					Adverse Reactions and Precautions
				Glycopeptides
					Vancomycin
					Mechanism of Action
					Clinical Uses
					Adverse Reactions and Precautions
					Telavancin, Delbavancin, and Oritavancin
					Mechanism of Action
					Clinical Uses
					Adverse Reactions and Precautions
				Quinupristin and Dalfopristin
					Mechanism of Action
					Clinical Uses
					Adverse Reactions and Precautions
				Oxazolidinones
					Linezolid
					Mechanism of Action
					Clinical Uses
					Adverse Reactions and Precautions
		Antimycobacterials
			Isoniazid
				Mechanism of Action
				Adverse Reactions and Precautions
			Rifampin, Rifabutin, and Rifapentine
				Mechanism of Action
				Adverse Reactions and Precautions
			Pyrazinamide
				Mechanism of Action
				Adverse Reactions and Precautions
			Ethambutol
				Mechanism of Action
				Adverse Reactions and Precautions
			Streptomycin
				Mechanism of Action
				Adverse Reactions and Precautions
		Antifungals
			Polyenes
			Mechanism of Action
			Clinical Uses
			Adverse Reactions and Precautions
			Azoles
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Echinocandins
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Flucytosine
				Mechanism of Action
				Clinical Use
				Adverse Reactions and Precautions
		Antiviral Agents
			Acyclovir and Valacyclovir
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Penciclovir and Famciclovir
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Ganciclovir and Valganciclovir
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Cidofovir
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Foscarnet
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Amantadine and Rimantadine
				Mechanism of Action
				Clinical Uses
				Adverse Reactions
			Oseltamivir, Zanamavir, and Peramivir
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
			Baloxavir Marboxil
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
					COVID-19 Antivirals
					Remdesivir
				Mechanism of Action
					Clinical Uses
					Adverse Reactions and Precautions
				Molnupiravir and Nirmatrelvir/Ritonavir
					Mechanism of Action
					Clinical Uses
					Adverse Reactions and Precautions
		Biologics
			COVID-19 and Monoclonal Antibodies
			Raxibacumab and Obiltoxaximab
				Mechanism of Action
				Clinical Uses
				Adverse Reactions and Precautions
		Respiratory Care Assessment of Antibiotic Therapy
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		References
	15 - Cold and Cough Agents
		Sympathomimetic (Adrenergic) Decongestants
			Topical Application
			Systemic Application
		Antihistamine Agents
			Effect of Histamine
			Histamine Receptors
			Antihistamine Agents
			Effects of Antihistamines
			Structure–Activity Relationships
			Use With Colds
			Treatment of Seasonal Allergic Rhinitis
		Expectorants
			Efficacy and Use
			Use in Chronic Bronchitis
			Mechanism of Action
			Expectorant Agents
				Iodine Products
				Guaifenesin (Glycerol Guaiacolate)
				Topical Agents
				Parasympathomimetics (Cholinergic Agents)
		Cough Suppressants (Antitussives)
			Agents and Mechanism of Action
			Use of Cough Suppressants
		Cold Compounds
			Treating a Cold
		Respiratory Care Assessment of Cold and Cough Agents
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		References
	16 - Selected Agents of Pulmonary Value
		α1-Proteinase Inhibitor (Human)
			α1-Antitrypsin Deficiency
				Genetics
			Indication for Drug Therapy
			Dosage and Administration
				Warnings and Adverse Reactions
		Respiratory Care Assessment of Therapy of α1-Proteinase Inhibitor (Human)
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		Smoking Cessation Drug Therapy
			Indication for Use
			Drug Formulations
				Nicotine Transdermal System
				Nicotine Polacrilex (Nicotine Resin Complex)
				Bupropion
				Varenicline (Chantix)
			Precautions
				Clonidine (Catapres)
				Nortriptyline (Pamelor)
		E-Cigarettes
			An Alternative or Substitute for Tobacco
		Respiratory Care Assessment of Smoking Cessation Drug Therapy
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		Nitric Oxide
			Indication for Use
			Dosage and Administration
			Pharmacology of Nitric Oxide
			Effect on Pulmonary Circulation
			Toxicity
			Contraindications
		Respiratory Care Assessment of Nitric Oxide
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		Synthetic Analogs of Prostacyclin
			Iloprost (Ventavis)
				Indication for Use
				Dosage and Administration
				Precautions
			Treprostinil (Tyvaso)
				Indication for Use
				Dosage and Administration
				Precautions
		Respiratory Care Assessment of Synthetic Analogs of Prostacyclin
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		Phosphodiesterase 4 Inhibitor
			Roflumilast (Daliresp)
				Indication for Use
				Dosage and Administration
				Precautions
		Respiratory Care Assessment of Phosphodiesterase 4 Inhibitor
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		Cystic Fibrosis Transmembrane Conductance Regulators
			Indication for Use
			Dosage and Administration
			Precautions
		Respiratory Care Assessment of CFTR Agents
		Insulin Human (Recombinant DNA Origin)
			Insulin Human (Afrezza)
				Indication for Use
				Dosage and Administration
				Precautions
		Respiratory Care Assessment of Inhaled Insulin
			Before Treatment
			During Treatment and Short Term
			Long Term
			General Contraindications
		References
	17 - Neonatal and Pediatric Aerosolized Drug Therapy
		Off-Label Use of Drugs in Neonatal and Pediatric Patients
		Factors Affecting Neonatal and Pediatric Aerosol Drug Delivery
			Effect of Age on Aerosol Lung Dose
			Effect of Small Tidal Volumes, Short Respiratory Cycles, and Low Flow Rates
				Effect on Small Volume Nebulizer
				Effect on Reservoir Dose
		Nebulized Drug Distribution
		Clinical Response to Aerosolized Drugs in Neonatal and Pediatric Patients
		Selection of Delivery Devices
			Nebulizers
			Pressurized Metered Dose Inhalers
			Dry Powder Inhalers
		Use of Selective Agents in Neonatal and Pediatric Patients
			Antibiotics
			Mucoactive Agents
			Aerosol Surfactants
			Antiinflammatory Drugs and Antibiotics
			Aerosolized Peptides and Proteins
			Prostacyclin Analogs for Pulmonary Hypertension
		Adherence, Compliance, and Cooperation During Aerosol Therapy
			Facemasks Design, Fitting, Crying, and “Blow-By”
			High-Flow Nasal Cannula
			Nebulizer Hood
		Parent Education on Inhalation Therapy
		Aerosol Administration in Intubated Neonatal and Pediatric Patients
		Summary
		References
Unit C
Critical Care, Cardiovascular, and Polysomnography Agents
	18 - Skeletal Muscle Relaxants (Neuromuscular Blocking Agents)
		Uses of Neuromuscular Blocking Agents
		Physiology of the Neuromuscular Junction
		Nondepolarizing Agents
			Mechanism of Action
			Pharmacokinetics of Nondepolarizing Agents
			Metabolism
			Adverse Effects
				Cardiovascular Effects
				Histamine Release
				Inadequate Ventilation
			Reversal of Nondepolarizing Blockade
		Depolarizing Agents
			Mechanism of Action
			Metabolism
			Reversal
			Adverse Effects
				Sensitivity to Succinylcholine
		Neuromuscular Blocking Agents and Mechanical Ventilation
			Precautions and Risks
			Use of Sedation and Analgesia
			Interactions With Neuromuscular Blocking Agents
			Choice of Agents
		Monitoring of Neuromuscular Blockade
		References
	19 - Diuretic Agents
		Renal Structure and Function
			Glomerular Filtration
			Electrolyte Filtration and Reabsorption
			Acid–Base Balance
		Diuretic Groups
			Thiazide and Thiazide-Like Diuretics
			Loop Diuretics
			Carbonic Anhydrase Inhibitors
			Potassium-Sparing Diuretics
			Osmotic Diuretics
		Diuretic Combinations
		Drug Interactions
		Adverse Effects
			Hypovolemia
			Hypokalemia
			Acid–Base Disorders
			Glucose Changes
			Ototoxicity
		Special Situations
			Pregnancy, Lactation, and Children
			Acute Respiratory Distress Syndrome
			Diuretic Use in Neonates and Infants
			Furosemide and Fluid Overload
		References
	20 - Drugs Affecting the Central Nervous System
		Neurotransmitters
		Psychiatric Medications
			Antidepressants
			Mood Stabilizers
			Antipsychotics
			Drugs for Alzheimer Dementia: Cholinesterase Inhibitors
			Anxiolytics
			Barbiturates
			Other Hypnotics
		Ethyl Alcohol
		Pain Treatment
			Nonsteroidal Antiinflammatory Drugs
			Opioid Analgesics
				Routes of Opioid Administration
				Opioid Inhalation
			Local Anesthetics
			Epidural Analgesia
			Combinations of Analgesic Classes
		Chronic Pain Syndromes
		Anesthesia
			Conscious Sedation
			Standards for Providing Conscious Sedation
		Central Nervous System and Respiratory Stimulants
		References
	21 - Vasopressors, Inotropes, and Antiarrhythmic Agents
		Overview of Cardiovascular System
			Factors Affecting Blood Pressure
		Agents Used in the Management of Shock
			Catecholamines
				Norepinephrine (Levophed) and Epinephrine (Adrenalin Chloride)
				Isoproterenol (Isuprel)
				Dopamine
				Phenylephrine
				Vasopressin (Pitressin)
				Midodrine (Proamatine)
				Angiotensin II – GIAPREZA
				Vasopressor-Induced Extravasation and Management
			Inotropic Agents
				Dobutamine
				Phosphodiesterase Inhibitors: Inamrinone and Milrinone
				Cardiac Glycosides: Digoxin (Lanoxin)
		Electrophysiology of Myocardium
			Ablation With Radiofrequency Current
			Implantable Cardioverter-Defibrillators
		Pharmacology of Antiarrhythmics
			Class IA
				Quinidine
				Procainamide
				Disopyramide
			Class IB
				Lidocaine
				Mexiletine
				Tocainide
			Class IC
				Flecainide (Tambocor)
				Propafenone (Rythmol)
			Class II
				β Blockers
			Class III
				Amiodarone (Cordarone)
				Dronedarone (Multaq)
				Dofetilide (Tikosyn)
				Sotalol (Betapace and Betapace AF)
				Ibutilide (Corvert)
			Class IV
				Calcium Channel Blockers
			Miscellaneous
				Digoxin (Lanoxin)
				Adenosine (Adenocard)
		Management and Pharmacotherapy of Advanced Cardiac Life Support
			Sudden Cardiac Death
			Epinephrine
			Vasopressin
			Atropine (AtroPen)
			Sodium Bicarbonate
			Magnesium Sulfate
		Alternative Routes of Medication Administration
			Intraosseous Route
			Endotracheal Route
		References
	22 - Drugs Affecting Circulation: Antihypertensives, Antianginals, Antithrombotics
		Hypertension
			Epidemiology and Etiology
			2020 and 2021 Management of Hypertension Guidelines Update
			Pathophysiology
			Hypertensive Crisis
		Hypertension Pharmacotherapy
			Angiotensin-Converting Enzyme Inhibitors
			Angiotensin II Receptor Blockers
			Direct Renin Inhibitors
			Calcium Channel Blockers
			β Blockers
			Diuretics
				Potassium-Sparing Diuretics
				Thiazide and Thiazide-Like Diuretics
				Loop Diuretics
			Aldosterone Antagonists
			Centrally Acting Adrenergic Agents
			α1-Adrenergic Antagonists
			Antiadrenergic Agents
			Vasodilators
		Angina
			Epidemiology, Etiology, and Pathophysiology
			Pharmacotherapy
				Nitrates
				Ranolazine
		Antithrombotic Agents
			Formation and Elimination of Acute Coronary Thrombus
			Anticoagulant Agents
				Heparins: Unfractionated Heparin and Low-Molecular-Weight Heparin
				Direct Thrombin Inhibitors
			Direct Oral Anticoagulant Agents
				Warfarin (Coumadin)
				Direct Oral Anticoagulants and Drug Interactions
				Potential Reversal Agents for Direct Oral Anticoagulants
				Four-Factor Prothrombin Complex Concentrate (Kcentra) for Warfarin Reversal
			2021 CHEST Anticoagulation Guidelines Update
			Antiplatelet Agents
				Aspirin
				Dipyridamole
				Clopidogrel (Plavix)
				Ticlopidine (Ticlid)
				Prasugrel (Effient)
				Ticagrelor (Brilinta)
				Cangrelor (Kangreal)
				Cilostazol (Pletal) and Pentoxifylline (Trental)
				Vorapaxar (Zontivity)
				Glycoprotein IIb/IIIa Inhibitors
			Thrombolytic Agents
		References
	23 - Sleep and Sleep Pharmacology
		History of Treatment of Sleep Disorders
		Progession of Sleep
		Neurophysiologic Mechanisms
			Arousal and Wakefulness
				Ascending Reticular Activating System
				Thalamic Mechanisms of Arousal
			Sleep Onset and Processes That Maintain Sleep
				Two-Process Model of Sleep Regulation
			Circadian Processes and Chronobiology
				Circadian Timing System
				Suprachiasmatic Nucleus: The Central Oscillator
				Circadian Rhythm and Metabolism
				Chronopharmacology
				Melatonin as a Chronobiotic and Chronohypnotic Agent
		Sleep Disorders: Causes and Treatments
			Insomnia
			Restless Legs Syndrome and Periodic Limb Movement Disorder
			Narcolepsy
			Parasomnias
		References
Appendix A - Answers to Self-Assessment Questions and Clinical Scenarios
Appendix B - Units and Systems of Measurement
Appendix C - Acceptable Mixtures of Most Commonly Prescribed Respiratory Care Drugs
Glossary of Selected Terms
Index
IBC