Adrenergic bronchodilators mimic the actions of
a. cAMP.
b. acetylcholine.
c. penicillin.
d. epinephrine.
ANS: D
Penicillin is an antibiotic, not a bronchodilator. All adrenergic (sympathomimetic) bronchodilators are either catecholamines or derivatives of catecholamines. Catecholamines, or sympathomimetic amines, mimic the actions of epinephrine more or less precisely, causing tachycardia, elevated blood pressure, smooth muscle relaxation of bronchioles and skeletal muscle blood vessels, glycogenolysis, skeletal muscle tremor, and central nervous system stimulation.
REF: p. 98 | p. 99
Relaxation of smooth airway muscle in the presence of reversible airflow obstruction is a general indication for the use of
a. mucolytics.
b. adrenergic bronchodilators.
c. antiinfective agents.
d. steroids.
ANS: B
Short-acting b2 agonists such as albuterol and levalbuterol are indicated for relief of acute reversible airflow obstruction in asthma or other obstructive airway diseases. Although mucolytics may help reduce the increased mucus production associated with complicated asthma, they do not reverse bronchoconstriction. Antiinfective agents help fight bacterial or viral infections, but they do not reverse airflow obstruction. Steroids help fight the inflammation associated with asthma; however, they are not fast-acting and cannot reverse airflow obstruction associated with bronchoconstriction.
REF: p. 98
Disease states that could benefit from the use of adrenergic bronchodilators include which of the following?
Asthma
Bronchitis
Emphysema
Bronchiectasis
Pleural effusion
a. 1 and 3 only
b. 2, 4, and 5 only
c. 1, 2, 3, and 4 only
d. 1, 2, 3, 4, and 5
ANS: C
Adrenergic bronchodilators would not reverse a pleural effusion. The general indication for use of an adrenergic bronchodilator is relaxation of airway smooth muscle in the presence of reversible airflow obstruction associated with acute and chronic asthma (including exercise-induced asthma), bronchitis, emphysema, bronchiectasis, and other obstructive airway diseases.
REF: p. 98
Short-acting b2 agonists are indicated for
a. reduction of airway edema.
b. relief of acute reversible airflow obstruction.
c. maintenance of bronchodilation.
d. thinning of secretions.
ANS: B
Steroids, not b agonists, are useful in reducing airway swelling. Short-acting b2 agonists such as albuterol and levalbuterol are indicated for relief of acute reversible airflow obstruction in asthma or other obstructive airway diseases. Long-acting b agonists are used for maintenance bronchodilation. b agonists are not mucus-controlling agents.
REF: p. 98
Your patient is diagnosed with persistent asthma. Which type of drug would you recommend for maintenance bronchodilation and control of bronchospasm?
a. Short-acting adrenergic agent
b. Long-acting adrenergic agent
c. a-adrenergic agent
d. Mucolytic agent
ANS: B
Short-acting adrenergics are effective rescue medications, but they do not provide the long-term relief needed with the nocturnal symptoms often associated with persistent asthma. Long-acting agents, such as salmeterol, formoterol, arformoterol, indacaterol, and olodaterol are indicated for maintenance bronchodilation and control of bronchospasm and nocturnal symptoms in asthma or other obstructive diseases. Adrenergic agents that are a-specific may not provide the b-specific bronchodilation necessary in the control of persistent asthma. Mucolytics do not produce bronchodilation; many may actually cause bronchoconstriction as a side effect. The topic of corticosteroids has not yet been discussed. The best answer from the given choices is long-acting adrenergic agents. The question is trying to ensure the understanding of the difference between “rescue” medications and “maintenance” medications.
REF: p. 98
Your patient presents with postextubation stridor. You recommend racemic epinephrine for its
a. a-adrenergic vasoconstricting effect.
b. short-acting b2-adrenergic effect.
c. long-acting b2-adrenergic effect.
d. b1-adrenergic effect.
ANS: A
Racemic epinephrine is often used via either inhaled aerosol or direct lung instillation for its strong a-adrenergic vasoconstricting effect, to reduce airway swelling after extubation or during epiglottitis, croup, or bronchiolitis or to control airway bleeding during endoscopy. This effect would provide short-term bronchodilation, but little or no relief from airway edema. The a-adrenergic vasoconstrictive response would slow the progress of airway edema.
REF: p. 98
You enter the room of a 2-year-old patient who presents with a “barking cough” typically associated with croup. Once the diagnosis is confirmed, which of the following medications could you recommend to help provide relief from subglottic swelling?
a. Albuterol
b. Levalbuterol
c. Racemic epinephrine
d. Salmeterol
ANS: C
Although effective bronchodilators, albuterol and levalbuterol provide little or no relief from airway swelling. Racemic epinephrine is often used via either inhaled aerosol or direct lung instillation for its strong a-adrenergic vasoconstricting effect, to reduce airway swelling after extubation or during epiglottitis, croup, or bronchiolitis or to control airway bleeding during endoscopy. Salmeterol is a long-acting bronchodilator.
REF: p. 98
In a patient who is receiving large doses of catecholamines, which side effect would you expect to see?
a. Decrease in blood pressure
b. Constriction of bronchial smooth muscle
c. Diuresis
d. Bradycardia
ANS: C
Catecholamines, or sympathomimetic amines, mimic the actions of epinephrine more or less precisely, causing tachycardia, elevated blood pressure, smooth muscle relaxation of bronchioles and skeletal muscle blood vessels, glycogenolysis, skeletal muscle tremor, and central nervous system stimulation.
REF: p. 99 | p. 100
Levalbuterol is
a. the same as albuterol.
b. the single (R)-isomer of albuterol.
c. an equal mixture of (R)-isomers and (S)-isomers.
d. the same as racemic epinephrine.
ANS: B
Albuterol is a racemic mixture, denoted by (R)-isomers and (S)-isomers. Levalbuterol, released in 1999, is the first synthetic inhaled solution available as the single (R)-isomer of racemic albuterol, not a racemic form of epinephrine.
REF: p. 103
Epinephrine stimulates which sites?
a
b1
b2
M3
a. 2 only
b. 4 only
c. 1, 2, and 3 only
d. 2, 3, and 4 only
ANS: C
Epinephrine is a potent catecholamine bronchodilator that stimulates both a and b receptors. Because epinephrine lacks b2-receptor specificity, side effects such as tachycardia, blood pressure increase, tremor, headache, and insomnia are prevalent.
REF: p. 100
Epinephrine is indicated for which of the following?
Treatment of infections
Severe allergic reactions
Acute asthma episodes
Cardiac stimulation
a. 1 and 4 only
b. 2 and 3 only
c. 2, 3, and 4 only
d. 1, 2, 3, and 4
ANS: C
Epinephrine occurs naturally in the adrenal medulla and has a rapid onset but a short duration because of metabolism by catechol O-methyltransferase (COMT). It is used both by inhalation and subcutaneously to treat patients with acute asthmatic episodes. It is also used as a cardiac stimulant, based on its strong b1 effects. Self-administered intramuscular injectable doses of 0.3 mg and 0.15 mg are marketed to control systemic hypersensitivity (anaphylactoid) reactions.
REF: p. 100
Racemic epinephrine comes in what percent solution?
a. 0.05%
b. 1.25%
c. 2.25%
d. 5.0%
ANS: C
Because only the (R)-isomer is active on adrenergic receptors, a 1:100 strength formulation of natural epinephrine (injectable formulation) is used for nebulization, whereas a 2.25% strength racemic mixture is used in nebulization.
REF: p. 100
The keyhole theory indicates that the larger the side-chain attachment to a catechol base, the
a. shorter the duration of action.
b. more easily it is metabolized.
c. more easily it is broken down by catechol O-methyltransferase (COMT).
d. greater the b2 specificity.
ANS: D
Duration of action is not affected by the side-chain attachment. All catecholamines are rapidly inactivated by COMT. Duration of action of all catecholamines is readily limited by COMT. The theory that explains the shift from a activity to b2 specificity has been termed the keyhole theory of b sympathomimetic receptors: The larger the side-chain attachment to a catechol base, the greater the b2 specificity. If the catecholamine structural pattern is seen as a keyhole shape, the larger the “key” (side chain), the more b2 specific is the drug.
REF: p. 101
Catecholamines are inactivated by
a. AchE.
b. COMT.
c. cGMP.
d. ATP.
ANS: B
Acetylcholinesterase (AchE) is not associated with catecholamines. Despite the increase in b2 specificity with increased side-chain bulk, all catecholamines are rapidly inactivated by the cytoplasmic enzyme catechol O-methyltransferase (COMT). This enzyme is found in the liver and kidneys as well as throughout the rest of the body. Epinephrine is a catecholamine. Adenosine triphosphate (ATP) is used in the production of energy within a cell. Cyclic guanine monophosphate (cGMP) is a nucleotide produced by b2-receptor stimulation.
REF: p. 101
Catecholamines may be given by which of the following routes?
Inhalation
Subcutaneous
Oral
Injection
a. 4 only
b. 2 and 4 only
c. 1, 2, and 4 only
d. 2, 3, and 4 only
ANS: C
Catecholamines are unsuitable for oral administration because they are inactivated in the gut and liver by conjugation with sulfate or glucuronide at the carbon-4 site. Because of this action, they have no effect when taken by mouth, limiting their route of administration to inhalation or injection.
REF: p. 111
Albuterol is available in which of the following forms?
Syrup
Nebulizer solution
Metered dose inhaler (MDI)
Oral tablets
Dry powder inhaler (DPI)
a. 2 and 3 only
b. 1, 2, and 5 only
c. 3, 4, and 5 only
d. 1, 2, 3, and 4 only
ANS: D
Albuterol is available in various pharmaceutical vehicles in the United States, including oral tablets, syrup, nebulizer solution, MDI, and extended-release tablets.
REF: p. 99
Salmeterol is
a. a long-acting b-adrenergic agent.
b. another name for albuterol.
c. available in nebulizer solution only.
d. indicated for acute asthma attacks.
ANS: A
Salmeterol, a b2-selective receptor agonist, is available in a dry powder formulation in the Diskus® inhaler. The effects of salmeterol may last 12 hours or more. Albuterol and salmeterol are different drugs with different bronchodilating profiles. The onset of action for salmeterol is between 14 minutes and 22 minutes, rendering it unacceptable as a rescue-type medication.
REF: p. 105
Long-acting b2 agonists are indicated for
a. acute asthma attacks.
b. mucus reduction.
c. treating infections.
d. maintenance therapy for asthmatics.
ANS: D
The onset of action of many long-acting bronchodilators makes them unsuitable as a rescue medication. b2 agonists are used mostly for their bronchodilatory effects and are not antiinfective agents. Although b2 agonists exert some stimulation of mucociliary clearance, they do not reduce mucus production. Long-acting bronchodilators are useful in controlling nocturnal symptoms and provide a more convenient dosing schedule. The topic of corticosteroids has not yet been discussed. The best answer from the given choices is long-acting adrenergic agents. The question is trying to ensure the understanding of the difference between “rescue” medications and “maintenance” medications.
REF: p. 107
The bronchodilating action of adrenergic drugs is due to stimulation of
a. a receptors.
b. cholinergic receptors.
c. b1 receptors.
d. b2 receptors.
ANS: D
a-receptor stimulation has a vasoconstriction and vasopressor effect. Stimulation of cholinergic receptors may cause bronchoconstriction. b1 stimulation increases myocardial conductivity, heart rate, and contractile force. The bronchodilating action of the adrenergic drugs is due to stimulation of b2 receptors located on bronchial smooth muscle.
REF: p. 108 | p. 109
b1-receptor stimulation
a. causes vasoconstriction.
b. provides upper airway decongestion.
c. increases heart rate and contractile force.
d. relaxes bronchiole smooth muscle.
ANS: C
a-receptor stimulation causes vasoconstriction and a vasopressor effect; in the upper airway (nasal passages), this effect can provide decongestion. b1-receptor stimulation causes increased myocardial conductivity, increased heart rate, and increased contractile force. b2-receptor stimulation causes relaxation of bronchial smooth muscle, with some inhibition of inflammatory mediator release and stimulation of mucociliary clearance.
REF: p. 109
Smooth muscle relaxation most likely occurs as a result of
a. a decrease in intracellular cAMP.
b. an increase in intracellular cAMP.
c. an increase in ATP.
d. a decrease in ATP.
ANS: B
Activation of adenylyl cyclase by the Gs protein causes an increased synthesis of the second messenger, cyclic adenosine 3‘, 5‘-monophosphate (cAMP). An increase in cAMP may lead to smooth muscle relaxation by increasing the inactivation of myosin light chain kinase, an enzyme initiating myosin-actin interaction and subsequent smooth muscle contraction. An increase in cAMP also leads to a decrease in intracellular calcium. ATP is used for cellular energy production.
REF: p. 109
Inhalation is the preferred route of administering adrenergic bronchodilators for which of the following reasons?
Rapid onset of action
Smaller dosage used
Reduced side effects
Drug delivered to target organ
Safe and painless route
a. 1 and 2 only
b. 3 and 4 only
c. 1, 3, and 5 only
d. 1, 2, 3, 4, and 5
ANS: D
Inhalation is the preferred route for administering b-adrenergic drugs for all the following reasons:
Onset is rapid.
Smaller doses are needed compared with oral doses.
Side effects such as tremor and tachycardia are reduced.
Drugs are delivered directly to the target organ (i.e., lung).
Inhalation is painless and safe.
REF: p. 111
Continuous nebulization of inhaled b agonists has been used for
a. severe asthma.
b. pneumonia.
c. cystic fibrosis.
d. emphysema.
ANS: A
The administration of inhaled adrenergic agents by continuous nebulization has been used for management of severe asthma, in an effort to avoid respiratory failure, intubation, and mechanical ventilation. The Guidelines for the Diagnosis and Management of Asthma released by the 2007 National Asthma Education and Prevention Expert Panel Report 2 (NAEPP EPR 2) also recommend 2.5 to 5 mg of albuterol by nebulizer every 20 minutes for three doses and 10 to 15 mg/hr by continuous nebulization. Because a nebulizer treatment takes approximately 10 minutes, giving three treatments every 20 minutes requires repeated therapist attendance. Continuous administration by nebulizer may simplify such frequent treatments. Pneumonia is an interstitial process, and unless there is a bronchoconstrictive component to the disease, a b agonist would be of little use. Cystic fibrosis is a chronic disease, and although a b agonist may be useful to reverse any accompanying bronchoconstriction, its use as a continually nebulized medication is unwarranted. Similar to cystic fibrosis, emphysema is a chronic disease process, and unless the patient is having an acute episode accompanied by bronchoconstriction, continuous nebulization would be unwarranted.
REF: p. 112
The dosage recommended by NAEPP EPR 2 for continuous nebulization of adrenergic agents is
a. 5 to 8 mg/hr.
b. 8 to 12 mg/hr.
c. 10 to 15 mg/hr.
d. 20 to 30 mg/hr.
ANS: C
The Guidelines for the Diagnosis and Management of Asthma released by the 2007 National Asthma Education and Prevention Expert Panel Report 2 (NAEPP EPR 2) recommend 2.5 to 5 mg of albuterol by nebulizer every 20 minutes for three doses and 10 to 15 mg/hr by continuous nebulization.
REF: p. 112
Your patient is receiving her third continuous nebulizer of albuterol (15 mg/hr). Which potential complications should you be on the lookout for?
Hypokalemia
Cardiac arrhythmias
Hyperglycemia
Premature ventricular contractions
Tremor
a. 2 and 4 only
b. 1, 2, and 5 only
c. 1, 2, 4, and 5 only
d. 1, 2, 3, 4, and 5
ANS: D
Potential complications include cardiac arrhythmias, hypokalemia, and hyperglycemia. Unifocal premature ventricular contractions have been reported, and significant tremors may occur. Subsensitivity to continuous therapy has not been observed. Close monitoring of patients receiving continuous b agonists is necessary and includes observation and cardiac and electrolyte monitoring. Selective b2 agonists, such as albuterol, should be used to reduce side effects.
REF: p. 113
When monitoring a patient using Ventolin, which side effect would you expect to see?
a. Sleepiness
b. Muscle tremor
c. Bradycardia
d. Hypotension
ANS: B
Side effects of sympathomimetic drugs include insomnia, muscle tremor, and tachycardia. Bradycardia and hypotension would be a result of parasympathetic stimulation.
REF: p. 113
You are ordered to extubate a mechanically ventilated patient who has recently undergone open heart surgery. On postextubation assessment you note that the patient has stridor with mild retractions. What type of pharmacologic agent would you recommend?
a. b2 adrenergic
b. a adrenergic
c. Anticholinergic
d. Sympatholytic
ANS: B
The a-adrenergic vasoconstricting effect of racemic epinephrine reduces swelling in the airway.
REF: p. 98
Which of the following is a b-agonist formulation that is a single isomer approved by the U.S. Food and Drug Administration (FDA) for aerosol delivery?
a. Epinephrine
b. Albuterol
c. Levalbuterol
d. Tiotropium
ANS: C
Although epinephrine and albuterol have b-agonist effects, they are both racemic mixtures. Tiotropium is a parasympathomimetic drug. Levalbuterol is the FDA-approved single-isomer formulation of a b-agonist drug.
REF: p. 103
What is the rationale for using the single-isomer agent levalbuterol instead of racemic albuterol?
a. The (S)-isomer is thought to promote bronchoconstriction.
b. The (S)-isomer is a weak bronchodilator.
c. The (R)-isomer is thought to cause tachycardia.
d. The (R)-isomer is thought to cause tremors.
ANS: A
Although the (S)-isomer is not active on adrenergic receptors, it may not be altogether inactive. Several effects of the (S)-isomer may promote bronchoconstriction.
REF: p. 102 | p. 103
What is the main difference between salmeterol and formoterol?
a. Formoterol is short-acting, and salmeterol is long-acting.
b. Formoterol has a slower onset and peak effect compared with salmeterol.
c. Formoterol is more b2-specific than salmeterol.
d. Formoterol has a quicker onset and peak effect than salmeterol.
ANS: D
Both salmeterol and formoterol are considered long-acting bronchodilators; however, the time to effect of formoterol is considered to be 2 to 3 minutes, whereas the time to effect of salmeterol is approximately 10 minutes.
REF: p. 105
What is the indication for use of a short-acting b agonist in asthma?
a. As maintenance therapy in reversible airflow obstruction
b. As rescue therapy in reversible airflow obstruction
c. As an antiinflammatory agent in reversible airflow obstruction
d. As an antiinfective agent in respiratory infections
ANS: B
Short-acting b agonists are used to treat acute reversible airflow obstruction by inducing bronchodilation. They were given the name “rescue medications” in the Guidelines for the Diagnosis and Management of Asthma released by the 2007 National Asthma Education and Prevention Expert Panel Report 2 (NAEPP EPR 2).
REF: p. 107
Is it appropriate to use Arcapta Neohaler as a rescue bronchodilator?
a. Yes
b. No
ANS: B
The slower peak effect and prolonged activity of indacterol make it a better choice as a maintenance drug than as a rescue agent.
REF: p. 105 | p. 106
Which procedure would tell you that a patient has reversible airway obstruction?
a. Inspection—patient is short of breath when walking less than 25 ft
b. Pulmonary function tests before and after bronchodilator therapy
c. Pulse oximetry
d. Wheezing on auscultation
ANS: B
Inspection, auscultation, and pulse oximetry would be of little value if the patient is not having an attack. Only pulmonary function tests (along with a methylcholine challenge, if necessary) before and after bronchodilator therapy would provide enough information for a diagnosis.
REF: p. 118
You receive an order to administer 5 mL of albuterol by small volume nebulizer (SVN). Which of the following should you do?
a. Confirm the order on the chart and administer as directed
b. Have your supervisor administer the treatment
c. Call the physician to confirm the medication dose
d. Give 0.5 mL of medication because that is probably what the physician meant to write
ANS: C
The normal adult dose of albuterol is 2.5 mg, or 0.5 mL of concentrated drug. The order as written calls for 10 times the normal amount of active drug and should be questioned.
REF: p. 99
You are administering an aerosolized bronchodilator to your patient. Her pretreatment pulse was 86 beats/min. You would stop the treatment if her pulse reached
a. 90 beats/min.
b. 100 beats/min.
c. 110 beats/min.
d. 120 beats/min.
ANS: C
If the patient’s heart rate increases by greater than 20% from its pretreatment rate, stopping the treatment may be warranted.
REF: p. 113 | p. 114
A 7-year-old boy has been given multiple aerosolized albuterol treatments over the last several days. His father tells you that every time a respiratory therapist administers a treatment, a few minutes later the saturation falls. You explain to the father that this is
a. abnormal and call the physician.
b. abnormal and you will try to change the medication to levalbuterol.
c. normal because of increased perfusion to poorly ventilated areas.
d. normal because you are giving the treatment with air.
ANS: C
A decrease in arterial oxygen pressure (PaO2) has been noted with b agonist administration during bronchospasm and is probably due to an increase in perfusion to poorly ventilated areas of the lung.
REF: p. 116
What is the generic name of Arcapta Neohaler?
a. Proventil HFA
b. ProAir HFA
c. Indacaterol
d. Arformoterol
ANS: C
Proventil and ProAir are trade names for albuterol. Arformoterol is a generic name for Brovana.
REF: p. 105 | p. 106
Metaproterenol can be taken orally because:
a. It has a fast peak time, about 3 to 5 minutes.
b. It does not contain chlorofluorocarbons (CFCs).
c. It is an antibiotic.
d. It resists inactivation by catechol O-methyltransferase (COMT).
ANS: D
Because metaproterenol is not inactivated by COMT, it has a significantly longer duration of action of 4 to 6 hours compared with the short-acting catecholamine bronchodilators. Metaproterenol can be taken orally because it resists inactivation by sulfatase enzymes in the gastrointestinal tract and liver. Metaproterenol is slower to reach a peak effect (30 to 60 minutes) than epinephrine.
REF: p. 102
A drug that exhibits its pharmacologic activity once it is converted inside the body to its active form is called
a. the asthma paradox.
b. a prodrug.
c. downregulation.
d. a sympathomimetic.
ANS: B
Asthma paradox refers to the increasing incidence of asthma morbidity and especially asthma mortality despite advances in the understanding of asthma and availability of improved drugs to treat asthma.
Prodrug refers to a drug that exhibits its pharmacologic activity once it is converted inside the body to its active form.
Downregulation refers to long-term desensitization of b receptors to b2 agonists, caused by a reduction in the number of b receptors.
Sympathomimetic refers to producing effects similar to the effects of the sympathetic nervous system.
REF: p. 98
Your patient requires a once daily long-acting b2 agonist. The physician asks for your suggestion regarding medication choice. What medication would you suggest?
a. Brovana
b. Arcapta Neohaler
c. Performist
d. Serevent Diskus
ANS: B
Long-acting b2 agonists Brovana, Performist, and Serevent are all taken twice daily. Arcapta Neohaler is a once daily DPI long-acting medication.
REF: p. 105 | p. 106
The dosage and route for arformoterol is
a. 5 to 8 mg PO.
b. 2.5 mg tid via nebulization.
c. 15 mg bid via nebulization.
d. 90 mg tid via MDI.
ANS: C
Brovana (arformoterol) is available via SVN: 15 mg/2 mL unit dose, bid.
REF: p. 105
Which of the following medications is an ultra-long-acting b-agonist approved for the treatment of COPD?
a. Striverdi Respimat
b. Xopenex
c. VoSpire ER
d. AccuNeb
ANS: A
Xopenex is levalbuterol and Accuneb is albuterol, both SABA indicated for relief of acute reversible airflow obstruction in asthma or other obstructive airway diseases. VoSpire ER is an extended release tablet form of albuterol.
REF: p. 106 | p. 107
Your patient is receiving continuous albuterol treatment for an acute exacerbation of her asthma. What would you monitor during her treatment?
The patient’s subjective reaction to treatment
The patient’s heart rate
The patient’s pulse oximeter saturation
Laboratory values (CBC)
a. 1 and 2 only
b. 2 and 3 only
c. 2, 3, and 4 only
d. 1, 2, 3, and 4
ANS: D
During Treatment and Short Term
Assess the patient’s subjective reaction to treatment for any change in breathing effort or pattern.
Assess arterial blood gases or pulse oximeter saturation, as needed, for acute states with asthma or COPD, to monitor changes in ventilation and gas exchange (oxygenation).
Note the effect of b agonists on blood glucose (increase) and potassium (decrease) laboratory values, if high doses, such as with continuous nebulization or emergency department treatment, are used.
REF: p. 112
Which of the following is the generic name for Brovana?
a. Formoterol
b. Salmeterol
c. Olodaterol
d. Arformoterol
ANS: D
Salmeterol Serevent Diskus
Formoterol Perforomist, Foradil
Arformoterol Brovana
Indacaterol Arcapta Neohaler
Olodaterol Stiverdi Respimat
REF: p. 99
Which of the following is the generic name for Arcapta Neohaler?
a. Indacterol
b. Salmeterol
c. Olodaterol
d. Arformoterol
ANS: A
Salmeterol Serevent Diskus
Formoterol Perforomist, Foradil
Arformoterol Brovana
Indacaterol Arcapta Neohaler
Olodaterol Stiverdi Respimat
REF: p. 99
Which of the following is the generic name for Performist?
a. Indacterol
b. Salmeterol
c. Formoterol
d. Arformoterol
ANS: C
Salmeterol Serevent Diskus
Formoterol Perforomist, Foradil
Arformoterol Brovana
Indacaterol Arcapta Neohaler
Olodaterol Stiverdi Respimat
REF: p. 99
Which of the following is the generic name for Striverdi Respimat?
a. Indacterol
b. Salmeterol
c. Olodaterol
d. Arformoterol
ANS: C
Salmeterol Serevent Diskus
Formoterol Perforomist, Foradil
Arformoterol Brovana
Indacaterol Arcapta Neohaler
Olodaterol Stiverdi Respimat
REF: p. 99
Which of the following medications are classified as ultrashort-acting adrenergic bronchodilators based on their duration of action?
Racemic epinephrine
Formoterol
Albuterol
Indacaterol
Arformoterol
Olodaterol
a. 1, 2, and 4 only
b. 1 only
c. 4 and 7 only
d. 1, 4, 7, and 8 only
ANS: B
Refer to Table 6-1.
REF: p. 99
Which of the following medications are classified as short-acting adrenergic bronchodilators based on their duration of action?
Racemic epinephrine
Formoterol
Albuterol
Levalbuterol
Arformoterol
Olodaterol
a. 2 only
b. 3 and 4 only
c. 2, 3, and 6 only
d. 4, 5, and 6 only
ANS: B
Refer to Table 6-1.
REF: p. 99
Which of the following medications are classified as long or ultra long-acting adrenergic bronchodilators based on their duration of action?
Indacterol
Formoterol
Albuterol
Indacaterol
Arformoterol
Olodaterol
a. 1 only
b. 4 only
c. 4 and 6 only
d. 5 and 6 only
ANS: C
Refer to Table 6-1.
REF: p. 99
Which of the following medications are given only once daily?
Formoterol
Albuterol
Indacaterol
Arformoterol
Levalbuterol
Olodaterol
a. 1 and 4 only
b. 4, 5 and 6 only
c. 3 and 6 only
d. 1, 4, 5, and 6 only
ANS: C
Refer to Table 6-1.
REF: p. 99
Chapter 07: Anticholinergic (Parasympatholytic) Bronchodilators
Gardenhire: Rau’s Respiratory Care Pharmacology, 9th Edition
MULTIPLE CHOICE
An anticholinergic that can be administered via aerosolization is
a. ipratropium bromide.
b. albuterol sulfate.
c. glycopyrrolate.
d. atropine.
ANS: A
Ipratropium is approved specifically for maintenance treatment of airflow obstruction in chronic obstructive pulmonary disease (COPD). Albuterol is not an anticholinergic; it is an adrenergic. Glycopyrrolate is not approved for inhalation. Atropine is not recommended for inhalation because of its widespread distribution in the body and the availability of the approved drug ipratropium bromide.
REF: p. 123
The combination of albuterol and ipratropium bromide can be delivered by which of the following methods?
Tablet
Nebulizer
Injection
MDI
Soft-mist inhaler
a. 2 only
b. 1, 3, and 4 only
c. 1, 2, and 4 only
d. 2, 4, and 5 only
ANS: D
Combivent is available in three formulations for bronchodilator use: as a hydrofluoroalkane-propelled MDI (HFA MDI) with 17 µg/puff, as a nebulizer solution of 0.02% concentration in a 2.5-ml vial, giving a 500-µg dose per treatment, and as a soft-mist propellant-free Respimat inhaler.
REF: p. 123
Incruse Ellipta® is approved for
a. exacerbation of chronic obstructive pulmonary disease (COPD).
b. thinning of dried secretions.
c. acute bronchoconstriction.
d. maintenance treatment of airflow obstruction in COPD.
ANS: D
Umeclidinium (Incruse Ellipta) is a long-acting anticholinergic approved by the FDA for once-daily maintenance treatment of airflow obstruction in patients with COPD.
REF: p. 123
Combivent® is a combination drug including which two medications?
a. Albuterol and salmeterol
b. Salmeterol and ipratropium bromide
c. Albuterol and ipratropium bromide
d. Pirbuterol and ipratropium bromide
ANS: C
Ipratropium and albuterol (Combivent®) is a combination metered dose inhaler (MDI) product, with the usual doses of each agent (18 µg/puff of ipratropium, 90 µg/puff of albuterol).
REF: p. 123
Cholinergic stimulation produces which of the following effects?
Bronchoconstriction
Increased mucus secretion
Miosis
Decreased heart rate
Salivation
a. 4 only
b. 1, 3, and 5 only
c. 2, 3, and 4 only
d. 1, 2, 3, 4, and 5
ANS: D
Cholinergic stimulation of muscarinic receptors on airway smooth muscle and submucosal glands causes contraction and release of mucus. Miosis, bradycardia, and salivation are also potential effects of cholinergic stimulation.
REF: p. 127
Mucociliary slowing, bronchodilation, and increased heart rate all are a result of
a. cholinergic agents.
b. adrenergic agents.
c. anticholinergic agents.
d. parasympathetic agents.
ANS: C
Cholinergic agents decrease the heart rate, cause bronchoconstriction, and induce mucus secretion. Adrenergic agents do not cause mucociliary slowing. Anticholinergic agents block parasympathetic tone and may cause mucociliary slowing, bronchodilation, and increased heart rate. Parasympathetic agents decrease heart rate and cause bronchoconstriction.
REF: p. 127
Quaternary ammonium compounds such as ipratropium bromide
a. are ineffective as inhaled agents.
b. do not cross lipid membranes easily.
c. are distributed quickly throughout the body when inhaled.
d. have no role in respiratory care.
ANS: B
Quaternary ammonium compounds are effective when inhaled (e.g., Atrovent®). Generally, quaternary ammonium compounds do not cross lipid membranes easily and do not distribute throughout the body when inhaled. Atrovent® is used frequently in respiratory care.
REF: p. 127
Ipratropium bromide is indicated to treat which of the following?
a. Allergic rhinitis
b. Maintenance therapy in patients with COPD
c. Nonallergic rhinitis
d. All of the above
ANS: D
Ipratropium bromide is approved specifically for maintenance treatment of airflow obstruction in chronic obstructive pulmonary disease (COPD). Ipratropium bromide (Atrovent® nasal spray) is also available for treatment of rhinopathies and rhinorrhea, including nonallergic perennial rhinitis, viral infectious rhinitis (colds), and allergic rhinitis, if intranasal corticosteroids fail to control symptoms.
REF: p. 123
Quaternary ammonium compounds cause bronchodilation by
a. blocking cholinergic sites.
b. stimulating cholinergic sites.
c. blocking adrenergic sites.
d. stimulating adrenergic sites.
ANS: A
Quaternary ammonium compounds cause bronchodilation by blocking cholinergic contractile action. In the nasal passages, ipratropium reduces hypersecretion, the basis for its use in rhinitis. As an anticholinergic, the compound would not stimulate cholinergic sites. Quaternary ammonium compounds do not act on adrenergic sites.
REF: p. 128 | p. 129
Patients using ipratropium aerosols should be instructed to avoid allowing the aerosol to come in contact with their
a. hair.
b. nose.
c. eyes.
d. ears.
ANS: C
Ipratropium nasal spray is useful in various respiratory disorders, but it may cause pupillary dilation and lens paralysis. Ipratropium has no known effect on human hair or the human ear.
REF: p. 131
Activating an Atrovent® inhaler in the eye may cause
a. blindness.
b. pupil dilation.
c. pupil constriction.
d. scarring of the cornea.
ANS: B
Pupillary dilation and lens paralysis may result, not total blindness. Corneal scarring is not a known risk factor.
REF: p. 131 | p. 132
Cardiac effects of aerosolized ipratropium bromide include which of the following?
a. Increased heart rate
b. Increased blood pressure
c. Increased heart muscle contractility
d. Little or no effect
ANS: D
Ipratropium bromide has minimal effects on heart rate or blood pressure when given by inhaled aerosol. However, several more recent meta-analyses have suggested that ipratropium and tiotropium may cause an increase in cardiovascular events. When other meta-analyses were conducted and reexamined, no incidence of cardiovascular involvement from inhaled anticholinergics was found. Currently, no information has been conclusive in showing that these agents have any adverse effects on the cardiovascular system.
REF: p. 131
Drugs that competitively block the action of acetylcholine at parasympathetic postganglionic effector cell receptors are called
a. muscarinic agents.
b. adrenergic agents.
c. antimuscarinic agents.
d. cholinergic agents.
ANS: C
Anticholinergic bronchodilators are specifically parasympatholytic, that is, antimuscarinic, agents, blocking the effect of acetylcholine at the cholinergic (muscarinic) receptors on bronchial smooth muscle. Adrenergic agents initiate a sympathomimetic action. Cholinergic agents would initiate an action at the effector cell receptor.
REF: p. 126 | p. 127
The most common side effect of anticholinergic bronchodilators is
a. dry mouth.
b. increased heart rate.
c. wheezing.
d. delirium.
ANS: A
The most common side effect seen with this class of bronchodilator is dry mouth.
REF: p. 131
Possible side effects of aerosolized Atrovent® include which of the following?
Flulike symptoms
Pharyngitis
Bradycardia
Dry mouth
Dyspnea
a. 1, 2, and 3 only
b. 1, 2, and 4 only
c. 1, 2, 4, and 5 only
d. 1, 2, 3, 4, and 5
ANS: C
The most common side effect seen with this class of bronchodilator is dry mouth. The small volume nebulizer (SVN) solution has also been associated with additional side effects in a few patients, including pharyngitis, dyspnea, flulike symptoms, bronchitis, and upper respiratory infection. Bradycardia is not a potential side effect of aerosolized Atrovent®.
REF: p. 131
Results of a patient’s pulmonary function test (PFT) show that the peak flow rate increased the most when she inhaled an aerosolized sympathomimetic agent and an aerosolized parasympatholytic agent. You would recommend that she be given which of the following?
a. Ventolin® MDI
b. Serevent Diskus® DPI
c. Combivent Respimat®
d. Foradil® DPI
ANS: C
Ventolin® MDI, Serevent Diskus®, and Foradil® are sympathomimetic agents only. Combivent Respimat® is a combination sympathomimetic (albuterol) and parasympatholytic (ipratropium bromide).
REF: p. 132 | p. 133
Which of the following is a once-a-day anticholinergic?
a. Atropine
b. Ipratropium bromide
c. Glycopyrrolate
d. Umeclidinium bromide
ANS: D
If used as an inhaled drug, atropine sulfate must be administered several times daily. Ipratropium bromide has a duration of only 4 to 6 hours. Glycopyrrolate is a quaternary ammonium derivative of atropine that, similar to ipratropium, does not distribute well across lipid membranes in the body. It is usually administered parenterally as an antimuscarinic agent during reversal of neuromuscular blockade, as an alternative to atropine, with fewer ocular or central nervous system side effects. It has a duration of approximately 6 hours. Umeclidinium bromide (Incruse Ellipta) has a duration of up to 24 hours and needs to be administered only once daily.
REF: p. 123
Which of the following statements regarding ipratropium bromide are true?
It is a first-line choice of bronchodilator for chronic obstructive pulmonary disease (COPD).
It can be combined with a b agonist for maintenance bronchodilation in COPD.
It is added to a b agonist in severe asthma episodes that do not respond to a b agonist alone.
It is a leukotriene modifier used to treat step 3 asthma.
a. 1 and 4 only
b. 2 and 4 only
c. 1, 2, and 4 only
d. 1, 2, and 3 only
ANS: D
b agonists and anticholinergic agents may have an additive effect when used to combat COPD. Ipratropium bromide is an anticholinergic (parasympatholytic) drug, not a leukotriene modifier.
REF: p. 132 | p. 133
Tiotropium bromide exhibits receptor subtype selectivity for which of the following receptor types?
a. M1 only
b. M2 only
c. M1, M2, and M3
d. M1 and M3
ANS: D
Tiotropium exhibits receptor subtype selectivity for M1 and M3 receptors. The drug binds to all three muscarinic receptors (M1, M2, and M3) but dissociates much more slowly than ipratropium from the M1 and M3 receptors; this results in a selectivity of action on M1 and M3 receptors.
REF: p. 129 | p. 130
Which of the following patient populations may benefit from anticholinergic agents?
a. Patients experiencing acute, severe episodes of asthma not responding well to b agonists
b. Patients with psychogenic asthma
c. Patients with nocturnal asthma
d. All of the above
ANS: D
Anticholinergic (antimuscarinic) agents such as ipratropium do not have a labeled indication for asthma in the United States. Current asthma guidelines state that ipratropium may have some additive benefit when given with inhaled b agonists. Antimuscarinic bronchodilators are not clearly superior tob-adrenergic agents in treating asthma. Antimuscarinic and b-adrenergic agents have an approximately equal effect on flow rates in many patients. These agents may be especially useful in the following asthmatic patients: patients with nocturnal asthma, in which the slightly longer duration of action may protect against nocturnal deterioration of flow rates; patients with psychogenic asthma, which may be mediated through vagal parasympathetic fibers; asthmatic patients with glaucoma, angina, or hypertension who require treatment with b-blocking agents; patients with notable side effects from theophylline as an alternative to theophylline; and patients with acute, severe episodes of asthma not responding well to b agonists.
REF: p. 132 | p. 133
Which of the following is a term used to describe an agent that produces the effect of acetylcholine or an agent that mimics acetylcholine?
a. Parasympatholytic
b. Parasympathomimetic
c. Muscarinic
d. Antimuscarinic bronchodilator
ANS: C
Muscarinic (same as cholinergic) refers to an agent that produces the effect of acetylcholine or an agent that mimics acetylcholine.
Parasympatholytic refers to an agent that blocks parasympathetic nervous fibers.
Parasympathomimetic refers to an agent that produces effects similar to the parasympathetic nervous system.
Antimuscarinic bronchodilator (same as anticholinergic bronchodilator) refers to an agent that blocks the effect of acetylcholine at the cholinergic site.
REF: p. 122
Acetylcholine stimulates M3 receptors on airway smooth muscle, causing which of the following?
a. Bronchodilation
b. Bronchoconstriction
c. Decrease in mucous gland secretion
d. There are no M3 receptors in the airway.
ANS: B
Acetylcholine stimulates M3 receptor subtypes on airway smooth muscle and submucosal glands, causing contraction of smooth muscle and exocytosis of secretion from the mucous gland.
REF: p. 129 | p. 130
Which of the following is the generic name for Atrovent?
a. Aclidinium bromide
b. Tiotropium bromide
c. Ipratropium bromide
d. Umeclidinium bromide
ANS: C
DRUG BRAND NAME ADULT DOSAGE TIME COURSE (ONSET, PEAK, DURATION)
Ipratropium bromide Atrovent HFA HFA MDI: 17 mg/puff. 2 puffs qid
SVN: 0.02% solution (0.2 mg/mL), 500 mg tid, qid
Nasal spray: 21 mg; 42 mg; 2 sprays per nostril 2 to 4 times daily (dosage varies)
Onset: 15-30 min
Peak: 1-2 hr
Duration: 6 hr
Ipratropium bromide and albuterol Combivent Respimat SMI: ipratropium 20 mg/puff and albuterol 100 mg/puff, 1 inhalation qid Onset: 15 min
Peak: 1-2 hr
Duration: 6 hr
DuoNeb SVN: ipratropium 0.5 mg and albuterol 2.5 mg
Aclidinium bromide Tudorza Pressair DPI: 400 mg/inhalation, 1 inhalation bid Onset: 10 min
Peak: 2 hr
Duration: 12
Tiotropium bromide Spiriva DPI: 18 mg/inhalation, 1 inhalation daily (one capsule) Onset: 30 min
Peak: 1-3 hr
Duration: 24 hr
Umeclidinium bromide Incruse Ellipta DPI: 62.5 mg/inhalation, 1 inhalation daily Onset: 5-15 min
Peak: 1-3 hr
Duration: 24 hr
Umeclidinium Bromide and vilanterol Anoro Ellipta DPI: umeclidinium 62.5 mg/inhalation and vilanterol 25 mg/inhalation, 1 inhalation daily Onset: 5-15 min
Peak: 1-3 hr
Duration: 24 hr
REF: p. 123
Which of the following is the generic name for Incruse Ellipta?
a. Aclidinium bromide
b. Tiotropium bromide
c. Ipratropium bromide
d. Umeclidinium bromide
ANS: D
DRUG BRAND NAME ADULT DOSAGE TIME COURSE (ONSET, PEAK, DURATION)
Ipratropium bromide Atrovent HFA HFA MDI: 17 mg/puff. 2 puffs qid
SVN: 0.02% solution (0.2 mg/mL), 500 mg tid, qid
Nasal spray: 21 mg; 42 mg; 2 sprays per nostril 2 to 4 times daily (dosage varies)
Onset: 15-30 min
Peak: 1-2 hr
Duration: 6 hr
Ipratropium bromide and albuterol Combivent Respimat SMI: ipratropium 20 mg/puff and albuterol 100 mg/puff, 1 inhalation qid Onset: 15 min
Peak: 1-2 hr
Duration: 6 hr
DuoNeb SVN: ipratropium 0.5 mg and albuterol 2.5 mg
Aclidinium bromide Tudorza Pressair DPI: 400 mg/inhalation, 1 inhalation bid Onset: 10 min
Peak: 2 hr
Duration: 12
Tiotropium bromide Spiriva DPI: 18 mg/inhalation, 1 inhalation daily (one capsule) Onset: 30 min
Peak: 1-3 hr
Duration: 24 hr
Umeclidinium bromide Incruse Ellipta DPI: 62.5 mg/inhalation, 1 inhalation daily Onset: 5-15 min
Peak: 1-3 hr
Duration: 24 hr
Umeclidinium Bromide and vilanterol Anoro Ellipta DPI: umeclidinium 62.5 mg/inhalation and vilanterol 25 mg/inhalation, 1 inhalation daily Onset: 5-15 min
Peak: 1-3 hr
Duration: 24 hr
REF: p. 123
Which of the following is the generic name for Spiriva?
a. Aclidinium bromide
b. Tiotropium bromide
c. Ipratropium bromide
d. Umeclidinium bromide
ANS: B
DRUG BRAND NAME ADULT DOSAGE TIME COURSE (ONSET, PEAK, DURATION)
Ipratropium bromide Atrovent HFA HFA MDI: 17 mg/puff. 2 puffs qid
SVN: 0.02% solution (0.2 mg/mL), 500 mg tid, qid
Nasal spray: 21 mg; 42 mg; 2 sprays per nostril 2 to 4 times daily (dosage varies)
Onset: 15-30 min
Peak: 1-2 hr
Duration: 6 hr
Ipratropium bromide and albuterol Combivent Respimat SMI: ipratropium 20 mg/puff and albuterol 100 mg/puff, 1 inhalation qid Onset: 15 min
Peak: 1-2 hr
Duration: 6 hr
DuoNeb SVN: ipratropium 0.5 mg and albuterol 2.5 mg
Aclidinium bromide Tudorza Pressair DPI: 400 mg/inhalation, 1 inhalation bid Onset: 10 min
Peak: 2 hr
Duration: 12
Tiotropium bromide Spiriva DPI: 18 mg/inhalation, 1 inhalation daily (one capsule) Onset: 30 min
Peak: 1-3 hr
Duration: 24 hr
Umeclidinium bromide Incruse Ellipta DPI: 62.5 mg/inhalation, 1 inhalation daily Onset: 5-15 min
Peak: 1-3 hr
Duration: 24 hr
Umeclidinium Bromide and vilanterol Anoro Ellipta DPI: umeclidinium 62.5 mg/inhalation and vilanterol 25 mg/inhalation, 1 inhalation daily Onset: 5-15 min
Peak: 1-3 hr
Duration: 24 hr
REF: p. 123
Which of the following is the generic name for Tudorza Pressair?
a. Aclidinium bromide
b. Tiotropium bromide
c. Ipratropium bromide
d. Umeclidinium bromide
ANS: A
DRUG BRAND NAME ADULT DOSAGE TIME COURSE (ONSET, PEAK, DURATION)
Ipratropium bromide Atrovent HFA HFA MDI: 17 mg/puff. 2 puffs qid
SVN: 0.02% solution (0.2 mg/mL), 500 mg tid, qid
Nasal spray: 21 mg; 42 mg; 2 sprays per nostril 2 to 4 times daily (dosage varies)
Onset: 15-30 min
Peak: 1-2 hr
Duration: 6 hr
Ipratropium bromide and albuterol Combivent Respimat SMI: ipratropium 20 mg/puff and albuterol 100 mg/puff, 1 inhalation qid Onset: 15 min
Peak: 1-2 hr
Duration: 6 hr
DuoNeb SVN: ipratropium 0.5 mg and albuterol 2.5 mg
Aclidinium bromide Tudorza Pressair DPI: 400 mg/inhalation, 1 inhalation bid Onset: 10 min
Peak: 2 hr
Duration: 12
Tiotropium bromide Spiriva DPI: 18 mg/inhalation, 1 inhalation daily (one capsule) Onset: 30 min
Peak: 1-3 hr
Duration: 24 hr
Umeclidinium bromide Incruse Ellipta DPI: 62.5 mg/inhalation, 1 inhalation daily Onset: 5-15 min
Peak: 1-3 hr
Duration: 24 hr
Umeclidinium Bromide and vilanterol Anoro Ellipta DPI: umeclidinium 62.5 mg/inhalation and vilanterol 25 mg/inhalation, 1 inhalation daily Onset: 5-15 min
Peak: 1-3 hr
Duration: 24 hr
