e all right everyone how's it going let me know if you can hear me okay I'm not uh unfortunately my my camera is at home and I'm in my office on campus but let me know if you can hear me oh perfect thank you Katie appreciate it started in just about a minute here put up the uh link for the sticky board if you have questions of course if you have question you can ask in the chat too uh we're doing ENT today so we did the opo just pre-recording and we're getting into our ears nose and throat uh so let's let's talk about it so all right so let start off with uh some antibiotics things you're commonly going to be seeing for ENT complaints kind of General upper respiratory tract kind of stuff as we get into it um my change uh some objectives we're going to cover today all the good stuff so let's talk about otitis media first good representative sort of example of an upper respiratory tract infection that we can um see pretty commonly especially in children uh we'll find it uh in several cases you can find this may start off as like a viral type of illness which may progress into bacterial often times enough though the bacteria are so likely to be present that we will go ahead and treat as such until kind of proven otherwise and so three bugs you're going to see come up quite frequently which will kind of be a recurring theme as we're going through this um include a strap pumo H influenza and then marks alak catalis and so this can change over time as things like you know vaccination rates change or maybe you know based off Community or geographic location can change but generally speaking our antibiotics are going to be geared towards these three bacteria since they are so commonly present and patients have kind of weird off type of bugs that are present sure but again we're going off of kind of the most common scenario we can talk about some exceptions as we go through here so our main state of therapy is typically Hy Doom oxicell uh the dosing specifically is not so important um to know for like testing purposes but I just include this for contacts uh but using higher doses of amoxicillin is uh useful for helping to over come some of that STP num numo resistance that we run into somewhat commonly there and then if it's more severe or if we have like resistant disease meaning like patients haven't like you know improved over the course of say three days or so we may step it up into using amoxic plus clavulanic acid so now we're including the betal laimas inhibitor to help expand coverage and overcome some of that resistance that you run into there um if we for whatever reason cannot use a pen due to let's say you know true infac allergy um some Alternatives would include seaner which if you recall is the third generation sephos sporin um that's probably going to be most preferred just because of resistance issues uh you could use a zithro however strap num numo resistance is a problem and so it probably say air on the side of using sethir as an alternative there if you have the choice and then treatment time wise can vary for a lot of people 5 to seven days can be sufficient um but for more severe cases you may go a little bit longer maybe go up to 10 and so using those shorter courses you run on the run the risk of not adequately treating the infection and it may come back so most people kind of air on that 7day sort of time frame for the most part if I mentioned they fail therapy and they've not improved over the course of 3 days or so um the another question may come up to says well have they received antibiotics recently because that may predispose the patient to more resistant bacteria and so you'll ask the question have you had antibiotics in the past three months and if so then you need to kind of Step Up your therapy a little bit more if not if they've not had any reent antibiotics um you could you know if you started on a moicy could graduate up into Augmentin or you could go to like a third gen seil spor like a SE here for example there um there are situations in which patients may require parental therapy so whether they can't tolerate oral medications for whatever reason or they have failed oral therapy they're not improving they we may need to escalate and so this gets into using parental sexin which youve ever recall is another third generation sephos sporn but you're just ensuring the bi availability is there and they can get that intramuscularly 3 days in a row um so basic basally we've had situations where patients can tolerate oral medications or maybe um for one reason or another you know they would basically come into the ER for this otitus media get their first shot of rosan then and then they would come back the next two days and not idealistically just with the fact that like that's another ER copay and that's taking time out of your day to go back to the year for 3 days and you know so there there are some downsides to that but in some rare instances that is necessary to do uh Switching gears and going into bacterial rhinosinusitis uh similar bacterial Spectrum Azo titis media however you do run the uh you know the spectrum of bugs kind of gets a little bit bigger here so you know could you see some G negative basili maybe some staff oras perhaps and so as such our coverage will start out a little bit wider than we might have for a more simple sort of otitis media just because are a little bit more sequestered away they may be a little bit more difficult to sort of like penetrate for drugs uh compared to you know the middle year for example here the issue you run into quite frequently is that a lot of patients will start to develop sinusitis sort of symptoms and then go you know say after a day or two we'll go to see a provider to get a script for an antibiotic and so frequently we're going to find that a lot of these cases tend to be viral in nature and so we do have some criteria that will help to guide us into determining if we think this is more likely bacterial and if it is then you want to give antibiotic so for example having symptoms are greater than 10 days um often times patients will have sort of what they call like a re sickening type of effect where they will be ill initially May tend to improve after a couple of days and then like day five or six those'll start to get sick again and in some cases this could be like a viral illness sort of setting the stage for for than a secondary bacterial infection but regardless once we have these criteria sort of met that's where we can then say okay let's go ahead and go with our antibiotics because for the vast majority of viruses patients may be infected with we don't really have any treatment for and it's self-limited enough where we don't really need it so here we're going to start once we have our presumptive diagnosis of bacterial sintis um we're going to go ahead and start with augmentin so skipping amoxicillin adding in the betal Lacamas inhibitor um will help to overcome a lot of that resistance due to things like H influenza for example there um if they had a penicilin allergy you could use a combination something like clintom plus the fixing which again using two drugs is not always ideal you could use you know level floxin as another alternative however um you know looking at things like levocin resistance in the area might be important to look at so if you check your antibiogram for example to see how frequently it is that you see you know Leo resistance May guide your therapy a little bit from that standpoint and then typically for kids because of their kind of difference in anatomy um treatment times are a bit longer so like 10 to 14 days versus adults you know five to seven other than that just general supportive care which I'll get into those specific agents in just a bit here um people do use these saline irrigations and they can be helpful they can improve some of their symptoms there um however it's really really important from like an educational standpoint to make sure that they are using um you know sterile water make sure they're using distilled water so that way they're not just using whatever is coming out of their tap or maybe they fill it up at a local Creek or something because you just don't know what could be growing in that water and there have been some rare instances of patients developing even you know secondary tertiary infections using contaminated water uh there's been some cases of a particular infection the brain eating amoeba called naria that has occurred as a result of these sinal sinus Rin is being used with contaminated water so don't want that to happen then getting into acute fitis so this can be frequently viral but if it is bacterial uh you know decent majority of cases are going to be due to this group a beta hemolytic strap and so this is something that we can test for so we have things like rapid strap test which can be useful in guiding our therapy which I'll talk more about here in just a second uh the goal though is to try to prevent these kind of secondary these supera of complications of H fitis so things like rheumatic fever and you know absis and things like that and so that's where we're going to try to aim our treatment to prevent those things from happening U we do have rapid strep test and so what we'll do is we'll do a test initially in the ER the urgin care if that's positive then we'll go ahead and just prescribe the antibiotics and be done with it if it's negative though we do still send for a follow-up culture because of the possibility of false negatives on the rapid strap meaning rapid strap was negative but they actually did have a bacterial infection so um those cultures usually take between like two and three days so if they were negative on the rapid strap you could send them home and then when those cultures come back you could review it and be like okay well actually what bacterial let's go ahead and prescribe this and so the patient go pick up at the pharmacy or whatever the case may be um so typically Moxy are goto here again keeping it simple um if patients for whatever reason could not use the oral route he didn't want to do 10 days worth of amoxicillin you could use the long acting benzine penicillin G that Bellin uh La as a one-time injection obviously tradeoffs are there so if you're looking at using an IM injection that could be painful for the patient it could be um you know anxiety and fear inducing could lead to some psychological trauma maybe the patient never has really gotten over now therapy years later because I got this nasty shot one time who could say right so for whatever reason those are kind of your biggest options there if truly penicillin allergic something as simple as a cflex like a first generation seos born cenda aith those could be Alternatives as well but probably try to keep it simple and go with the clex since that's cheap and easily available so those are systemic antibiotics used for a lot of these ENT sort of complaints here let's look at some odic options that we have for patients and so frequently especially for like a lot of like otitis externos and things like that um it will include a combination of an anti-infective plus a steroid and so we'll go a bit more in depth on term in terms of what steroids do for us but generally speaking the steroid is there to help reduce inflammation swelling and pain the patient may be experiencing and you have the anti-infective which will actually work to treat the infection itself so that's usually the the combo you're going to see there so for example if you see a codex that would include CPR flasin as an antibiotic and then dexamethasone as a anti-inflammatory property or anti-inflammatory um other options could include things like cporn which would have two antibiotics you have neomy and and polymix and B and then hydrocortisone as the steroid there or you could just find anti-infectives by themselves so special notes things to consider in terms of like drug selection for your patients here um first of which if patients experience any kind of hypers sensitivity increasing and itching or swelling or redness um it's most likely related to the neomy so that would be one thing to consider switching from if they started ctis sporn and they experience that probably the neis most likely and then if they have any kind of like ruptured tempic membrane or if they have tubes in place you don't want to use the polyx and B that has a tendency to affect the CIA the hair cells there and can cause AO toxicity you see hearing loss as a result so we don't want to do that so doing a good thorough exam making sure the ears look good before the temp Panic membranes intact would be necessary if you want to use something like a ctis spor the reason why you might use a quarter spor in the first place is because generally speaking it's much cheaper than some Alternatives so if you wanted to use cypro deex that is much much more expensive for who knows what reasons but but um there are instances so for example if I have one of the ENT docs Place uh ear tubes in or place tubes in place um patients will oftentimes get a prescription for three days worth of CeX to go home with in order to prevent any kind of like secondary infections from from taking place and again A lot of times these kids getting tubes placed or because of recurrent otitis media anyway so they're kind of prone to these infections and if they don't have like medic for example it can be like prohibitively expensive depending on their insurance coverage and so what do we do for those patients as an alternative and so we have a couple of Tricks here one of which happens to be utilizing some alternative agents here so what's neat is you could just use oxic by itself which replaces the cypro and the cyprex and then we can use dexamethasone which doesn't itself come as an odic product but we do have Opthalmic drops so we can take eye drops and place those in the ear and that substitutes for the Cy deex and that actually works out really well and is much much cheaper than CeX itself um so key point there eye products can go into the ear that's totally fine anything not made for the eyes you cannot place there because of the sensitivity of the eyes to things like tenic pH Etc so eye products can go anywhere else nothing else goes in the ey except for eye products they just going of keep that straight all right a couple antifungal agents you're going to run into um ketoconazol is a common thing we're going to see especially for U for example prevention of things like you know thrush or treatment of thrush you know oral candidasis um you know ketond has a lot of issues associated with it so for example you can see things like SI 34 inhibition and QT prolongation so for all those reasons while it could be effective for treating fungal infections it's not really ideal from you know all those in points there so frequently what we do as an alternative would be something like an ISTA and so the benefit here is that while it's useful for treating something like a thrush type of infection um it doesn't get absorbed systemically so you miss all of those side effects that you might see with something like an oral ketoconazol or something like that um maybe some J upset but that's really the biggest thing you're going to run into for the most part so patients can either Swish and spit so that way they get coverage in the back of the throat um they can swish and swallow whatever the case it doesn't get absorbed so we don't really care so much so that could be good for patients who are like imuno compromised who are prone to thrush could be good for patients who are on inhaled steroids which will get into when we discuss our pulmon pulmonology medications a bit later on the semester here okay so that's kind of the Infectious Disease aspect of things let's get into uh our talk of anti-inflammatory agents here so uh the first of which I will mention are the solic lates and this will kind of be our lead up into discussion of our ineds and kind of talk about the differences there between the groups compared to something like a Tylenol versus our cortico steroids and so we'll get into all of that U start with silicates just because this is kind of the oldest one out of the bunch Ian we've been using silicates for thousands of years if you think about aspirin coming from uh the bark of the willow tree we've been using this for sort of natural medicine for a good long time now and so if you're ever familiar or if you're ever curious about why aspirin is abbreviated is as because it stands for acetal salicylic acid so you can wow your friends with with your drug knowledge here um and so how these drugs are going to work these anti-inflammatories is through inhibition of cyc oxygenase so it's abbreviated as Cox Cox and so what you're going to find is is that through what we call the arachadonic acid pathway uh the enzyme cycle oxygenase is going to produce a lot of we call inflammatory cyto kindes things that induce inflammation like prostaglandins thromboxanes and whatnot and by inhibiting that enzyme you thereby inhibit the production of these inflammatory mediators unless you reduce inflammation so that does a couple of things for us it helps to reduce inflammation overall as an anti-inflamatory it provides analgesia meaning it's helping to treat pain and we're also going to find it works as an antipyretic and it treats fever so you have kind of like a three sort of different indications that you're going to be seeing these used for especially when it comes to um you know ENT complaints your typical cough and cold kind of stuff right um most of the agents we're going to talk about here at least today will be non-selective but be aware that there are two different types of Cox enzymes Cox one and then Cox 2 Cox 2 is what we call an inducible enzyme meaning its production only really gets ramped up when we have a need for inflammation so if I go and I stub my toe or something that will start to ramp up production of Cox 2 to start to introduce those inflammatory mediators to attract you know vean cells all kinds of other stuff that goes on during the inflammation Cascade it's an inducible enzyme Cox 2 Cox one is actually going to be what we call a constitutive enzyme meaning it's kind of always being produced in our body day in and day out and the reason why it's important to distinguish between the two there is because when you have pain or fever or inflammation Cox 2 is really what you want to focus on however most agents we use are non-selective so what happens if I inhibit Cox one well Cox one is responsible in part for producing the protective barrier that lines your stomach your stomach acid is like pepsin has a pH of like two it digests your stomach just like it would a hamburger however by having cox1 producing prostaglandins it stimulates production of this nice mucus layer that has a lot of bicarbon in it that neutralizes all stomach acid so you've probably heard a common complaint of people taking chronic insides or silicates is that they can cause peptic ulcers that's exactly why is because chronically if you're inhibiting Cox one including a bunch of other reasons um you will erode that lining away and can cause ulceration bleeding perforation in some cases and can be de if not [ __ ] treated early so we can talk more about Cox do selectivity I'll probably do that more so when I talk about pain management probably in next semester but kind of set in the stage here for the stuff that will apply these inets as we kind of get into this and another reason why to focus on these as well is because a lot of these agents we're going to talk about in this section here are going to be over the counter and because they are over the- counter they're readily available meaning patients have access to this 247 meaning they might be taking these products without your knowledge or maybe against your recommendations and that can lead to issues even just because of medications over the counter does not indicate anything about its safety levels because I will tell you I've seen plenty of cases of fatal picate poisoning or of Tylen overdoses or inset overdoses that have got they got really really sick patients so because of the way that the FDA has regulated a lot of these older drugs when they put in things like prescription versus OTC delineations a lot of these drugs have been around for so long they got grandfathered into the OTC category so like well I've been using them for a long time so they must be safe and effective when that may not always be the case sociate poisoning that stuff scares me because they can't get so toxic as we'll see so looking at this you can see another place where we have a lot of aspirin usage is also for cardiac reasons and I'll mention this ly here but basically at these lower dosages if you think about what patients take for cardiac protection they're taking a baby aspirin a day baby aspirin is like 81 milligrams and so this at this lower dosage has these nice anti-platelet effects which can prevent patient from having a heart attack for example you don't need a lot of it because aspirin works as an irreversible inhibitor of cyc oxygenase platelets don't have nuclei so they can't produce their own proteins after they're formed and thus once cyc oxy is inhibited in a platelet for the lifetime of that platelet aspirin is affecting it meaning you don't need a lot of aspirin in order to cover the platelets you have and then as you produce new platelets that little bit of aspirin will to deal with those as well and so if you think about the lifetime of a plet it's about a week about 7 to 10 days or so and so if you ever work in surgery for example you may tell a patient hey you're having this procedure you're on aspirin stop taking it a week prior to your procedure and by doing so that actually gives the body time to produce new platelets which will have easier time clotting than if they had been had aspirin present there so that's at the low dose at these slightly higher doses more kind of typical therapeutic dosages we think about um you see a lot of the antipyretic and analgesic actions here but as we start to go up and again of course the whole time you're seeing this risk for bleeding and bruising being a possibility as we get higher though we're going to see more of these signs of talism the early one often times being tentious they may complain of not ringing necessarily but um like kind of a muffled type of hearing they may be complaining about this um which can rapidly progress into being something quite fatal and again when I you know have someone presenting with a uh you know ibuprofen overdose I'm not too worried about that patient but a silate poisoning that can be really really nasty um Le to all these kind of metabolic complications here so from a safety standpoint I don't like aspirin a lot I'd rather someone take another type of inid which we'll talk about here in just a moment uh from that standpoint so Contra indications here we're going to see bleeding disorders because that will increase their propensity for bleeding already um pregnancy typically we'll avoid I'll talk a little bit more about pregnancy risk with inhibiting pych oxin here in just a little bit and we also do not want to use this in kids who've had a recent viral illness things like influenza things like the chickenpox because treating the symptoms of that Viral illness can put them at risk for developing something called raise syndrome which can be quite fatal and so this does not happen as often nowadays because there's a lot more safety recommendations and a lot more things put in place to try to prevent s slate use in this group but this can be it has been much more pres or prevalent in years past when we did not have as much info about this there was not as much public awareness of this but basically this raay syndrome is a fatty liver and seil opathy that can develop in kids so in particular less than 16 who've had a recent viral illness should not get aspirin they start to develop this sort of like lethargy and this sort of um you know vomiting and a lot of that early symptoms can look like a viral illness and as such it may not be caught until it's progressed in sort of these later stages where we start to see things like catic injury and we start to see CNS issues um to where we can eventually see fullon organ failure and and death that can occur here you kind of see the different five stages that you'll go through um early interventions really preferred if you can you know stop the medication get them early good supportive care is what's going to be necessary here um but generally speaking just say hey let's just not use aspirin in these younger patients if we can avoid it and again it's specifically kids have had a recent viral illness is what puts them at risk for this Ray syndrome we use aspirin kids not commonly but there are certain cases where you need to use it but these are things we' screen for so for example like Kawasaki's disease you see a lot of cites being used um they've had open heart surgery we'll use you know Cates so just be cautious and I mentioned Pepto bismal here just because um another thing you'll see used a lot for treatment of GI complaints but if you look at the active ingredient Pepto-Bismol it is bismuth sub solic late so even though it's not aspirin itself it does contain a solic late similar recommendations here for safety purposes so less than 16 years of age recent viral illness no solic lates used in them all right so patient education information you might provide for someone who's using this obviously um we can use it for fever pain anti-inflammatory sort of actions here um it's also important to remember and you'll see this posted in invite you to next time you're like in a drugstore Publix or Walmart wherever um go down the OTC aisle and just kind of check out the package info like the the recommendations and the warnings and things they put on these boxes um because it'll include a lot of similar info here because of the fact that they're taking this stuff over the counter um they may be treating the symptoms of something more severe and as such they can get into a situation in which they're masking the symptoms and not getting the care which may be necessary so they're treating a fever or pain and what if that's a bacterial infection so a lot of the information I have here is hey like hey they having fever for more than three days like maybe go see a provider and a lot of the truck manufacturers will put that on the box so that way they have plausible deniability if someone has gets into trouble from a legal standpoint but these are also good recommendation just in general U make sure they don't take ASA with other IDs because we'll find these actually do the same thing so you can increase your risk for toxicity there and of course if any kind of anticoagulants bleeding risk is going to go up as a result of that so you Ibuprofen and again if I'm looking at the safety profiles between Cates and and something like ibuprofen it's a world the difference um patients on ibuprofen um have much bigger safety profile therapeutic windows is a lot larger and so generally speaking if there's not a need for aspirin I'll recommend something like this instead and so I'll mention ipren and the proxin here for ENT purposes just because those are your two main available IDs when we get into talk of like pain management or like Rheumatology stuff Ortho stuff then I'll talk more about the other nids usually prescription based um how we use those and some of the caveats there but notice again here using for anti-inflammatory analgesic and antipyretic actions we don't use ibuprofen for cardio stuff mainly because it's a reversible inhibitor so while as or ibuprofen is in the system it can increase your bleeding risk once it has been eliminated your risk goes back to normal because all those little cyc oyas molecules in your platelets go back to normal and they can function again um like I mentioned still the mechanism is identical they're reversibly inhibiting cyc Ox one and two and so we'll still see there are some risk for things um like certain drug interactions I'll talk about here in just a moment um so typically fever pain inflammation ibuprofen is good to go to there uh I mentioned dosing here don't memorize dosing for my purposes I don't really care you know that um just to give you some context for how these drugs get used here now side effect here you can see again risk for things like gastric or doal ulcers because of that inhibition of cyc oyat if you lose those prostaglandins that cyc oxas also produces you are going to start to erode away that protective barrier and then all stomach acid and pepson can start to digest the stomach lining or dadal lining leading to these ulcers so if a patient is complaining of stomach pain while taking Motrin especially if they've been taking a lot of it or chronically it kind of points towards this being more likely to CAU so the two big reasons why patients get peptic ulcers is either inside use or it's hpylori those are the two main ones so if you real out h pylor I look for the insid that's probably going to be a player there now if you notice here it says edema fluid retention renal failure decrease cening clearance what's up with that because you know you're thinking this is over the counter shouldn't there shouldn't this be pretty safe to use but there can be issues that pop up here um I'm G to try to draw something out for you real quick okay so I'm going to I might have I've probably drawn this before um during like physio or something like that but I'll do it again just for uh comple the sake here so let's say for example we going talk about the kidneys real quick and so what I'm drawing here is a glus right so this is the start of a nefron we're looking at here and we're going to have basically blood flow coming in this direction and leaving here and then we're going to have some degree filtration happening so we're going to see that urine is starting to be produced here so looking at our sort of naming convention here this is going to be what we call the afferent arterial and this is called the eer arterial okay so how do we regulate filtration at the kidney it's based off of pressure okay so the more pressure there is within the Glarus the more filtration that happens so I could do that one of a couple of ways one I could decrease the diameter of the eeper material could squeeze on this and that causes filtration pressure to increase thus I can produce more urine okay and normally how this works is through the actions of angiotensin 2 okay so this is good kind of background for getting into discussions of cardio stuff a little bit later on um so this is not really important for our purposes here the other way that you could increase filtration pressure is to increase the diameter of the blood vessel of the a arterial through the actions of prostag glandon it's a prostaglandin causes that vasod dilation of the afferent arterial so if I were to then introduce an inid he's green for my inid inid I said that these work to decrease the actions of cycle oxygenase thereby decreasing production of pranin so incs are going to come in here and they get rid of the proag lanin meaning they get rid of this vasodilatory action here meaning the vessel is going to constrict leading to less blood flow coming in thess filtration pressure goes down leading to less urine production so if you're a healthy person you don't have history of kidney disease you're fine with this you can handle this because you have other compensatory mechanisms like Angiotensin 2 for example it's not no problem but if you have poor kidney function and you're decreasing the ability to produce that urine well that's going to one lead to issues in terms of getting rid of waste products getting rid of drugs also means you're holding on to more of this fluid leading to things like EMA can happen especially like in heart failure patients and things like that so that is why when they say hey watch out for ibuprofen it can fry your kidneys it is more so in those examples of patients who have pre-existing kidney disease who will then have you know kind of a chronic renal failure chronic renal issues you're then adding an acute sort of insult on top of that so you got to be cautious there because ineds are known to be a nephrotoxin and let's say for example you have a patient who's being admitted to the hospital let's say to the ICU they have sepsis and they're hypotensive they're already not you know profusing the kidneys well enough so maybe they're having the start of a kidney injury related to the sepsis issues there and if fever so we say well we got to treat the fever so let's give them ibuprofen to get their temp down well now you're adding ibuprofen on top of kidney injury being caused by the hypotension oh then also maybe say we're treating the infections we're giving imun glycosides and vomisin so it's easy to see patient get into situations we're having a lot of this adding insult injury so to speak we're adding additional nephrotoxins on these can synergize with one another so we do have some Alternatives we talk about that just in a moment here but just something to keep in mind and be careful of just because it's over the counter does not mean it is benign it can cause its own set of issues there so drug interactions wise you're going to see that largely this is going to be affecting medications that help to control blood pressure so for example drugs like ACE inhibitors they work less effectively because their effects on the kidneys um they'll have decreased secretion of drugs that are filtered through the kidneys like lithium that we use for bipolar disorder your diuretics won't work as well for example because of the kidney issues and so you can lead to things like you know decrease secretion of drugs like methotraxate which can cause really significant injury which we'll talk about the hemog section later on um and you increase the bleeding time leading to risk if patients are on anti-coagulants their bleeding risk is going to go up from there not to the same degree as as aspirin because of the the reversible nature of ibuprofen but can still occur why the drug is around okay so Contra indication wise we're going to see some of these are relative some of these are absolute keep in mind the difference absolute means you never ever do it relative meaning there may be some wiggle room maybe some situations where you're okay so obviously allergy don't want to do it okay um now these other ones are going to be kind of interesting so for example here past medical history of stomach ulcers or perforation or they have renal dysfunction there could be some instances where we may utilize ineds um there are certain things we can do either by adding the addition of or putting on additional medications which is never never ideal but sometimes we do um or maybe using a smaller dose or using it less frequently those are considerations we can think of here now um avoiding kids less than six months of age this is generally a pretty well held to rule in Pediatrics um the reason why this is is because there are some kids who are born with a congenital heart defect and maybe it's mild enough to where it's not noticeable initially and the reason why it might not be noticeable is because the kids will develop a patent ductus arteriosis okay and this allows for enough mixing of the blood and the hearts that way they're not symptomatic and if you were to close this off prematurely could end up leading to basically failure the the defect will become much more obvious and K get symptomatic so because of these the possibilities some of these kids being undiagnosed with these congenital heart defects we avoid inets and okay so what what does that two things have to do another well that pton ductus osis is kept open by using the body producing prostaglandins we said ineds reduce prag gland formation so you can actually cause this to close leading to kid becoming symptomatic so there's that what's also interesting too some kids are born with a patent ductus arteriosis where they don't need it and it's causing problems for them and what do we use to close that well we actually use inets we give IV ibuprofen for example to try to close that up instead of using surgical liation you can do a chemical liation there so keep these things in mind who not to use inid in is an important consideration even though the stuff is available you go and buy a ton of it right now with no real issue as I mentioned we'll talk more about other prescription inets when we get into discussions of things like pain management later on or R you rheumatologic conditions here but other OTC inets includes an neox being the most common one the same consideration same side effects same Contra indications the big difference so um the proxin having a longer halflife means you don't need to dose it as much so whereas ibuprofin typically like every you every six every eight hours you might give an a prox once or twice a day and so that may be beneficial from like a compliance type of standpoint there okay so those are the typical ineds I kind of lump aspirin in with the insets even though they do have their distinctions um then we get into Tylenol cenan paracetamol if you're from across the Atlantic and so you may see this being abbreviated as APAP and the APAP comes from again the chemical name so acetal par Amino phenol that's where the APAP comes from and so this one is unique in the fact that it is separate from the ineds in the fact that it has no anti-inflammatory activity it's a good analgesic and it's a decent anti pyritic those are the two main things we're going to use this for inflammation no way doesn't do it and so mechanistically speaking this is thought to also inhibit cycle oxygenase but the reason why it's not going to be working for inflammation is because if you have inflammation at a peripheral tissue you're producing a lot of like you know acids and peroxidases and stuff it ends up neutralizing the the doesn't work but centrally in the CNS H works great and so it's able to reduce that fever reduce pain signals reaching the brain and so very helpful for that um big thing with this one in terms of side effects wise time is like super tolerable B have very few side effects to this however the big thing to concern yourself with which I'm sure most of you know is that you do not want to use more than four grams per day for healthy adults the reason why that is is because as you start to exceed that you start to overwhelm the liver and it starts to deplete things like cofa fa s necessary for safely metabolizing Tylenol once you start to lose those co-actors and the liver can't continue to metabolize T safely starts to produce this nasty metabolite called nap key or napqi and so that is what causes the liver injury and liver failure you can see in the cases of things like Tylenol overdose and so all the recommendations that hey don't go with four grands in a day you know if they have history of liver disease I'd recommend even lower than that so like maybe not more than like three gram if you have to have to use it if it's your liver disease probably have them switch over to you know inet if it's tolerable um but really important about that and again you need to consider all sources of Tylenol because there are many analgesics out there that also include acetaminophen so looking at your popular opioids peret and L tab it's oxycodone hydrocodone respectively in combination with cedam minen and so so all the sources of cenum infant need to be accounted for for a daily total of four grams because if patients don't know any better if they look at their prescription bottle and it says hydrocodone acetaminophen and they're like well I'm not taking acetamin I'm taking Tylenol they may get themselves into trouble and so it's quite possible for patients to get into what I call Therapeutic Misadventures where they think they're not doing any harm but really get themselves into lot of issues and so um you the tal overdoses can can be acute can be someone trying to harm themselves and take a whole bunch at one time but often it is more of a chronic Insidious sort of onset and that could be dangerous too because patients may not notice it at first and it can go on for for some period of time there um yes so someone had a question here uh can you explain again how prostag glenans would keep the ductus arteriosis open yes uh let go and draw again let's do a new picture so um I'm going to do a very Cru scud um drawing here but let's assume we have the heart okay so you got your Atria and you got your ventricles down here so usually and again if my anatomy is is not um incorrect here the D theosis will lie somewhere between the ventricles right and so normally especially during fetal development this is kept open and so this is open this hole here is going to be through the actions of prostaglandins right and so what can happen is if kids born and they still have this openuct sosis if you were to give them an insid that would then get rid of the prostaglandins that could close when they needed it to be open essentially what's also kind of interesting there is that the flip slide is true as well we will sometimes have kids who are born prematurely who are not ready to have that close and so we'll actually give them synthetic prostag gland it's called a and so we'll give this to him as an IV drip why I picked such a long name to write here so we'll give out pradel to basically replace the protic glands they may not be producing anymore to keep this open but then if we had a kid who had a PDA we call him Pon inductor perosis we wanted to close it then I would just give an inset and just get rid of that naturally you could surgically liate it but we always try chemical first and then if that doesn't work then we do surgery so U hopefully I answered your question if not let me know okay um so again T all super safe uh just make sure the dosing is correct otherwise um they can't get themselves I'm pretty significant trouble there so um you know it's interesting too I was see online um I'm not on on Tik Tok or anything like that but I do browse Reddit um incessant and so it's always funny around New Year's Eve New Year's Day kind of thing where people always be like don't take Tylenol because it'll kill your your over don't take it for hangover because it'll kill your liver that's not usually the case it's not usually the acute Tylenol exposures if you take it because you have a headache you know just because you drink alcohol does not mean you can't take Tylenol um the problem you're run into though is going to be that chronic alcohol usage that chronic liver injury that happens over time that then predisposes patients to be more susceptible to that Tylenol so if you have that history of liver disease your patient does um you would again be more cautious than using tyone at all and then if you're going to use it make sure using smaller doses to account for that so that four gram limit like I mentioned for healthy adults with good livers that goes down probably some like three grams or even less so I just want to keep mind there okay so next let's talk about our antihistamines 43 minutes in I've only done 26 slides my goodness what's wrong with me um let's talk about histamine so histamine is a big component of the allergic response you know we think about it being caused causing this triple response the redness the wheel the flare so you're going to see these typical responses here you're see deasil dilation you're going to see that kind of vascular permeability such you get edema will start to form uh and you get this kind of surrounding sort of viso dilation the flare that happens and so at large that can cause all kinds of things so from a runny nose to scratchy eyes I mean just itchy eyes just all kinds of issues we can run into whether it be from a drug allergy environmental allergy animal allergy whatever the case may be histamines involved in all of this right and so we see there's primarily two main types of histamine receptors H1 and H2 H2 we're going to keep in hold for talking about gastrointestinal stuff later on next semester H1 is the main one we're going to focus on here because it has such huge effects on both the vasculature it can affect the bronchial smooth muscle to cause things like contraction there can cause um you know bronch secretions will increase as a result of histamines effects uh GI effects all kinds of things so because histamine is such a big component of the allergic response we're talking about it here and is a common group of medications used that would try to block the actions of histamine they get found in a lot of these cough and cold type of preparations here so like I mentioned increase mucous secretion increase smooth muscle tone in particular in the bronchial Airways so that can be a big problem patient having Anais for example they may have Airway compr romise um vascular permeability all that's responsible through the actions of H1 receptors okay um like I mention H2 is more so for things like gastric acid secretion here so we're going to find this to be more prominent um drug wise when we talk about GI stuff later on so I don't really focus so much on the H1 uh two receptors here so when we have H1 antagonist what we're going to find is they have a lot of really need effects both peripherally and we're also going to see the central effects as well say peripheral effects I'm saying out everything outside the CNS Central effects being within the CNS and so peripheral effects we're going to see reduction of both the bronchial and the GI smoth muscle contraction we're going to see reduction of that vasod dilation less secretions less edema less itching all perfect so if you're having any kind of like environmental allergy response drug response whatever the case may be this works to treat a lot of those symptoms there fortunately the downside you're going to see though are the central effects with the antihistamines and so um for example one of the big ones you run is sedation because histamine helps out with level of arousal of somebody so if I'm blocking that you can end up seeing decreased mentation they could become sleepy right um you will find that this is also very synergistic with other CNS depressants and so um actually had a cousin actually just recently experienced this where he was um feeling very dizzy kind of nauseous and so you know oh yeah for motion sickness I'll talk about that in a second um take a product called bony which has an antihistamine in it um he also has anxiety disorder so he took half his anex and he's all of a sudden just like I'm so I cannot stay what is going on I was like well you kind of Overdose yourself a little bit because adding a CNS depressant like a benzo deine like a XX or alcohol plus antihistamine they're going to work really well together and so that can lead to dangerous effects in some cases or in some cases may be pretty benign they may just be knocked out but imagine if you had someone who needed to go drive a car or truck or something like that it is very easy to see how these sedating effects could lead to things like car accidents and whatnot could be very dangerous so you know there there's also another case here where the therapeutic or the side effect of a medication could be used specifically for its as a therapeutic action and so for example the antihistamine called damine is marketed for sleep there an OTC medication um again be very cautious and educate against mix matching these other XS depressants because again they will synergized there um at low doses you typically see that sedation um however higher dosages and we'll see why in just a second you do run the risk of getting more into this sort of like excitation anxiety hallucination seizure kind of standpoint but interestingly kids even at low doses can develop what they call a paradoxical reaction and the reason why that is is because actually don't know the reason why it is but but it basically it means that they would have instead of getting sleepy they end up getting almost this like Restless like ants in the pants kind of feeling uh term for this we use this called akathesia and so akathesia can just have this like energy where they can't sit still they may get very anxious during this um they're bouncing off the walls and so that can be problematic if you know say you were trying to um dose your kid with antihistamine you know before bedtime or something because they're having some allergic responses and not sleeping well um you could use one of these and hopefully that would put them to sleep but they could get the opposite reaction and so you kind of don't know that until you administer to them and see how they respond to it some adults will you know maintain this throughout their life U most people it does resolve after childhood for the most part um I mentioned the excitation scene in overdose so one of the things you're going to run into is that in overdose and in some cases people will abuse antihistamines for the purposes of getting high so there is you know there's a a song by by uh Young the Giant I believe it's called it's called cough syrup this is kind of what they're getting at is a lot of these cough and cold preparations include drugs that you can get high off of I don't recommend it but people do this and so you got to be cautious because you can see this excitation which can lead up into things like seizures and can be fatal in some rare cases there how we combat these CNS effects though is because we're going to find that we have a first and a second generation set of antihistamines the first generation are much more likely to cause the CNS effects because they're able to cross the blood brain barrier much more readily versus second generation agents cannot do so they don't cross the blood brain barrier so they don't cause the CNS effects cause all the peripheral effects but they don't cause the CNS effects namely the sedation so if you have someone who needs to drive a truck cross country for example I'd be much more likely to recommend a second generation antihistamine for them than I would a first generation unless they're about to go to bed you know um a CER song was funny my wife always Associates the poison center with that song because it was my ringtone whenever I'm mom call for the poison Center for years and not anymore but um just she every time she hears that song she's like hey the poison Center's calling anyway um other non-specific actions we're going to see here as well and this is pertaining to the first generation drugs in particular includes the anti-ed actions the anti-muscarinic actions and anti- serotonergic don't worry so much about the seratonin aspects here but the big ones here are the treatment for things like motion sickness their vestibular sort of disturbances and also some of the antimuscarinic properties which we'll get into in just a moment so as an anttic we're going to find that it has to do both with the anti-histamine component but also a lot of the first generation antihistamines also are anti-muscarinic meaning they're blocking a cocoline in the CNS as well so this helps out with both actions in the chemo receptor trigger Zone but then also in places like the CATE where it can actually help in the vestibular apparatus to decrease some of the motion sickness can develop from being like on a cruise or using a VR headset anytime you have that mismatch between what your eyes are seeing and what your vestibular apparatus is feeling that mismatch can lead to nausea vomiting and so this helps to reduce that quite a bit um you know something like promethazine is really interesting because it has one of the strongest anti muscarinic actions there so it will help to really decrease the nausea vomiting U but also it's going to be super sedating and so if you're not familiar with promethazine um it is commonly combined with a drug called Codine Codine is um a kind of a weak anti uh weak opioid Agonist and so if you Everly promethazine and Codine being used together um it is uh being used as like an anti-tussive antiemetic type of drug there U but is popular um in certain circles uh as something called lean or purple drink or scissor or whatever you you want to call it they'll basically mix promethazine and coating along with things like um Sprite and Jolly Ranchers and they get this drink that is produce a high uh so to speak but it's funny because they call it lean because it's so sedating that when you see people using it they usually leaned over against the wall or something because they're about to fall asleep so again I would not recommend drug abuse if you can help it at all but the antimuscarinic action are also nice because it will help to dry the patient out so to speak meaning you're decreasing a lot of secretions like nasal secretions and tearing and and um all that again that does lead into side effects like dry mouth and things like that but again your Ms May Vary for some days so we're using this for allergic reactions motion sickness um sleep remedies over the counter for example here and as a big player for allergic responses namely to things like anaxes do peanuts or drugs or whatever the case may be so very helpful from that standpoint uh side effects wise sedation I mentioned there you can see GI disturbances a lot of these with these strong antimuscarinic properties what does that do to the GI track well slowing everything down so constipation can be a very common side effect if using these more chronically you see dry mouth and urinary retention all of that um hypers sensitivity is not usually a big problem here usually with like a topical um dosage form usually due to some inactive ingredients and stuff that can cause issues but otherwise um the antimuscarinic properties are a big one sedation those are the most common things you're going to run into so here is the list of our first generation versus second generation antihistamines and so looking at the difference between the first and second e some pretty Stark changes remember second generation can't get across the blood brain barrier so they don't cause a lot of the central actions if you look at the stive effects notice here very low To None anti medic actions none basically for second generation antol energic also quite low these other agents that are able to cross the blood bring barrier able to have these actions here which maybe that's what you're looking for and that could be the the right choice for your patient but if you wanted to avoid things like these sedative and anticholinergic actions the second gen drugs would be the one you want to go with okay so some of these are available over the counter things like chloramine dyen hydramine for example some are still only going to be available as a prescription based product like promethazine hydroxyzine um but you can easily get access to these over the counter um second generation wise we have things like cerine fenine and then ladine they also have some enan out there like know Leo cerine and um des and whatnot I don't mention them necessarily just because these are available over the counter you can get access to these they're cheaper than getting these newer prescription varieties here but they work just the same and have the zeeline as an intranasal product there so um the benefits of using something like an intranasal product are when it does help to localize the effects of the drug which may limit systemic act uh side effects and so using aistin just in the nose if that's all you're having is nasal symptoms that works out pretty well but if I'm having eye symptoms and nose symptoms and I'm itchy using a systemic actor is going to be more beneficial for the patient so again look at their catology and figure out what's going to be working best for them um reason I want to mention this here is just some commonalities amongst most of your nasal spray type of products here one of which can be bitter taste that's usually due to postnasal DP back of the tongue on the N nasal passage is where you're going to see that and then also some risk for or nose bleeding this happens more so if either you have like rectal trauma to the septum or if you're kind of like chronically drying out that needs mucosa that tends to be more prone to bleeding do the an muser S of actions there but excuse me generally speaking roles of um administering a nasal medication you're first you want to blow out the nose clear out all the boogies and whatnot so that way the medication can have as much contact surface area with the um tissue there you want the head tilted down so that way patients are not going to get a lot of medication going down the back of the throat there and you want to angle the spray away from the septum so the easy way to do that would be especially if patients are giving this themselves is use the right hand to administer drug into the left nostril so it kind of naturally points away and then vice versa use the left hand for the right nostril and that keeps it away from the septum to avoid any kind of like nasal trauma there as best you can um and then have not their head back make sure to clean off the tip well to avoid goodies and things like that growing uh and make sure patients don't share these products um that probably seems like common sense but these should be like a one product per patient kind of deal because you don't want them to spread anything from one another there and obviously if they're having any like nose bleeding have them discontinue if symptoms are not improving they could have something else going on have them follow up all right next getting into our corticosteroids here we're going to find that this falls into the category what call glucocorticoids um these are very powerful chemicals which are able to help decrease the inflammatory Cascade basically from the side of the nucleus on down so these are going to be basically either replacing or supplementing the normal cortisol that you produce from your adrenal glands and so these are able to decrease all aspects of inflammation these are very powerful what they do they do take some time to kick in so these are not going to be as quick acting as your antihistamines simply because these are working on things like Gene transcription and protein production but they can be very very powerful what they do and so starting up we'll talk about our more locally acting versions of the cortico steroids here so there's several that are available we have things like beone pide fluide fluticasone Mone and then trinolone get familiar with these because these are going to come up again when we get into our pulon py section as well because we're actually going to find that there are inhaled versions of these medications which are useful for things like asthma topd in some cases um they have inhaled versions and you don't want to get these two mixed up and you'd be surprised how often this can occur but they try to make the names sort of intuitive so for example Flo n you think nasal I think nose versus flow vent ventilatory breathing okay let's the lungs or you know you rhinocort versus Port Port would be the budesonide inhaled version there so some of these are available over the counter some of these are still prescription only kind of just depends on the product there just be cautious if you're doing like a med Rack or something not to get these two mixed up if you just type inazone in the electronic medical record I don't know what you're going to get first maybe the nasal product maybe the inhale product don't want to get those mixed up so these are typically for allergic ritis phasal motor ritis here um typical side effects are going run into it's pretty well tolerated um but you can't see unpleasant taste and then rarely can you run into things like nose bleeding septum perforation again more prominent if there's like nasal trauma that occurs here um interestingly one of the side effects you're run into with chronic steroid use is the fact that it uh impairs wound healing so maybe there's a little bit of trauma done to the septum and that kind of chronic exposure to the steroids may lead to this impaired wound healing which could make septum perforation that much more likely but not super common into that for the most part interaction wise nothing really noted here because they're just working in the nose so they're not really going to cause any systemic sort of issues which we will then compare to the systemic corticosteroids here in just a moment so first of which we have is dexamethasone so this is either given IV or Po and being given systemically is going to have systemic actions which could be really good if you're having let's say you're have rheumatoid arthritis having inflammation all over this could be good to treat that but if I'm just having you know allergy symptoms in my nose maybe the nasal product can be better so the question is like where are the symptoms at how diffuse is the disease questions like that so here have deth our representative example of the corticosteroids here synthetic corticosteroids and so we use this from drug hypersensitivity reactions you know really severe allergic ritis um however while effective for what they do and they're really good at what they do there's a ton of side effects associated with these so first of which these are not great for cardiac patients because they cause you to hold on to more fluid they cause your blood pressure to go up they cause you to become more emitus not great for heart failure patients for example these also will cause your glucose to go up remember cortisol is a stress hormone so if I'm giving exogenous stress hormones what do you need to do when you're running away from a threat you need glucose to power your muscles so glucose levels go up because you're causing the liver to produce more glucose from glycogen other side effects you can run into can include ocular symptoms for example increased intraocular pressure can happen so not good for glaucoma patients um you can see things like heroism you can see electrolyte disturbances all kinds of issues and they're immunosuppressive so you can see more risk for infection whether viral fungal bacterial what the case may be so the question is how do how do we kind of balance that out to make sure we're not going to be causing these undue side effects and so a lot of it has to do with the duration of use and also the dose that we're using as we're going to see here drug interaction wise again a ton of interactions here things like you know your diuretics aren't going to work as well because the Dex methasone causing you to hold on to more fluid but also you can end up losing potassium as a result of that so hypokalemia um you can see issues like patients diabetic medications are not going to work as well because the de meth bumping up their sugars we need to adjust their insulin dose for example in order to account for that see more arhythmia so a lot of side effects lot of drug interaction you can run into so you always want to be really you know judicious when deciding hey this is a good indication for a steroid because again it can cause all kinds of other issues they have any kind of systemic fungal infections going to suppress their ability to fight that even further so again they be you know absolute Contra indication here and then uh patient education wise again let them know hey you're going to be more prone to infection so maybe if you're going to be around a bunch of young children for example school age children maybe wear a mask who knows what you just be cautious is the best thing we can do make sure you're washing your hands routinely now if you notice here do not discontinue dexamethazone abruptly so this is in particular for more than a week I'm sure you've probably heard before of tapering steroids and so what that means is is that when your body is normally producing cortisol right why how does it produce cortisol well it's because your hypothalamus tells pituitary gland says hey we need some cortisol here send some chemicals down to make some cortisol and so you have things like act and all that's going to be involved here and so that will tell your adrenal glands hey he's time to produce some cortisol when you supply exogenous steroids you're going to find that you start to activate the negative feedback Lo because you're typically giving super physiologic amounts of steroids meaning higher than what the normal body usual level is by doing so that then tells the hypothalamus and the pituitary gland hey we have enough steroids around we don't need to send that signal anymore and so that stops the signal to the adrenal glands adrenal glands say hey I don't have a job to do I'm going to take a vacation so they start to shut down they start to atrophy so it's all well and good while you're providing that exogamous corticosteroid well what happened s if they're on it and again that happens usually takes about a week for that to occur the whole process so if it they've been on it for more than that week and you decide to stop the Dex methone all of a sudden and decide to quit cold turkey or the patient stops taking it you're going to be in a situation in which the dose the the amount of steroid in the body starts to drop off but the adrenal glands have not woken back up to start producing that cortisol again so you can run the risk of running into this adrenal insufficiency which is a big problem because you have issues regulating your blood sugar so your blood sugar be in in the tank your blood pressure is not going to be regulated well that's going to be in the tank too so they can get to potentially really lifethreatening situations so the rule is if they're on a steroid for more than a week you have to taper off of it so by gradually decreasing the dose of the steroid over the course of say a week two weeks however long depends on how much they on um by tapering it over that period of time you're then able to have a gradual transition from the Dex at the zone and then the cortisol coming back to replace it so if it's less than a week though which the great majority of these cases for ENT purposes they don't need it for more than a week if it's five days of dexamethazone or prazone whatever the case may be you don't need to taper so something a lot of people will falsely think they need to do they really don't if it's less than one week okay so keep that time frame in mind now um prazone and pricone prisone is a liquid form of prazone um works just the same as Dex Zone the only difference is like how you dose it basically due to one being more poent the other um same side effects same interactions same Contra indications all this still applies because essentially they're doing the same thing so I'm not going to spend a lot of time deling between the two because really it's just a matter of dosing usually for the most part okay then we get into some decongestion here so if we're having a lot of nasal stuffiness a lot of um nasal mucus production what not we have a couple options here first of which is going to be one called oxy metasin or afron and so this is a product that is a nasal spray that is nice to work just locally you know if you're just having nasal symptoms nasal stuffiness this can be quite effective for that um and so notice here though there's a there's a dosage limit here there a time frame you're you're stuck with here you only do three to five days max if you go beyond that you start to run into an issue where the body almost develops like a physical dependence on the drug and the reason why that is because normally how this works is by activating Alpha receptors you activate an alpha receptor you cause smooth muscle constriction so in the nose those little nasal capillaries you're causing them to constrict thus leading to less edema less mucous production if I'm constantly activating those Alpha receptors they're going to respond by down regulating because they're getting too activated so if you're on this for say a week straight or two weeks straight you're into a situation where those Alpha receptors are very much depleted they're downregulated and then what happens if you stop taking the medication well now you're relying on your natural Nori epinephrine to activate those Alpha receptors but there's way fewer of them so you see less activation and what you end up seeing is a rebound nasal congestion so basically instead of going back to their Baseline they get mega congested probably worse than what their nasal congestion was in the first place and and So to avoid this we say don't use it more than 3 to 5 days otherwise we have to build in a taper for the afron which we don't want to have to do this is a process called ritis medicamentosa it's a rebound ritis that occurs if it's used more than that three to five days so a lot of places for example they'll have like automatic stop dates so if we start afon in the hospital automatically stops that for three days because we don't have to deal with this problem here and he have new pharmacist one time who had a big counter CVS or walk whatever it was um he had three bottles of AF one either side one in the middle because he was so physically dependent on it he had to be constantly have it available and his notice his nose was starting to get stuffed up stuffed up again not a situation you want to be in so no more than three to five days because of a rebound nasal congestion again I probably mentioned this in the opo lecture I don't remember but um I usually ask a question about this or using um you know Visine in the eyes or something I say what's the problem if you stop if you after after using it for more than a week it's always rebound nasal congestion rebound you know ocular you know edema um students always forget this for whatever reason so this is a very unique thing time frame wise nowhere in 3 to five days keep that in mind okay so similar patient education what we saw for other nasal sprays again if patients are treating the symptoms of something like a bacterial infection they may not have Improvement so in those cases there why they say after 3 days if you're not improving go get checked out because again you don't want them masking s something more severe that may require like antibiotics or some other type of treatment there um looking at more systemic type of decongestion we then get into pseudo aedin um which is going to be working more systemically which is good if you're having like ocular and nasal symptoms here but also that carries more risk for other side effects so for example uh it being an alpha Agonist and causing vasil constriction this might be a problem for patients with tech with hypertension for example or it will make their hypertensive medications work less well however for some people though this is the only thing that works for them when they get a cold and they have that nasal congestion there um the notable thing about pseudo aedin is that it is used in some cases to produce me methamphetamines and so as such um there was a law passed I think back in the late 90s or so um where they did the combat methamphetamine act and they basically made pseudo fedrin not you know prescription only but it's behind the counter not over the counter but it's behind the counter and so what that means is is that you are restricted you have to be an adult to buy it you have to produce uh you know governmen issued ID you're limited on how much you can buy because they don't want people going from say Pharmacy to Pharmacy buying out their pseudo federan stock to make enamines see Breaking Bad you know all about it but um so as a result of that it's you have to have someone actually get it for you you kind of feel like a criminal trying to buy the stuff you know it makes it difficult so patients will often times not get the pseudo fedron they say well get whatever's on the actual store shelf and so what they'll see is something akin to this is PED PE and so you know you think pseudo aedon you think pseud fed there's a lot of monetary value linking a brand name when it comes to people going out and you know getting their OTC drugs think oh yeah I know I have nasal congest I need psea fed or my mom told me to buy psea fed right and so there's a lot of value in having that brand name on the store shelf but they couldn't put pseudo fedrin on store shelves anymore so what dides pseud fed do well they made pseud fed PE the PE stands for fenel Efron and you can get fenel Efron IV and it's a great Vasa constrictor it's terrible orally does not do its job and I was raing about this ever since I started teaching in PA education and um even the the FDA eventually brought out a big statement saying hey this this stuff doesn't work if you need something get the actual pseudo aedon if you're having need a congestion that's going to be the thing you want to get so I do not recommend this stuff go get the actual stuff from behind the counter I wouldn't recommend going behind the counter yourself they might get mad about that but have someone get the actual s sod of vagin for you all right um then to wrap up we're going to talk about some anti-tussive and expectorant here um first of which cough how do we treat cough um we know cough is caused by variety of things you know things like chemical mechanical irritance within the upper respiratory tract can sort of kick off this reflex of pathway it's really wild to see you know how high pressures you can develop from this and the speed of air you're forcing here um I mean there's cases where cough has caused like you rib fractures and plural diffusions and all kinds of nasty stuff here but most people just think it's kind of bothersome you know maybe it's keeping keeping them up at night um you know kids a lot of times will have like a post-nasal type of drip which will cause them to cough especially in the middle of the night which can then lead to potential vomiting which is never fun um and so our goal here is to try to prevent you know complication and reduce overall number and severity of these episodes patients are having so first of which is a prescription based product called benzonate or Tessalon and so they call them Tessalon pearls because if you look at them here you can see this kind of pearly looking sort of uh look to them um this makes it really attractive to kids especially if they see that because they think it looks like candy and so this can be a source for possible you know accidental exposure especially kids less than like six um but it works by and that's the izing these stretch receptors in the lungs so it works almost like a local anesthetic like you use lidocaine on the skin for example if you're going to suture somebody um good for you know relief of this kind of non-productive coughs usually if it's a productive type of cough you don't want to necessarily suppress that because if it has like bacteria you want them to get rid of it but for nonproductive coughs this is perfectly fine um one thing to note though is that um you know you can Google this but there are a list out out there of drugs you do not want to crush crush or chew and the reason why that is is because if you were to crush or chew this particular product um you actually get all of that drug in the mouth and that can actually cause oral numbness um and it doesn't treat your cough so have them actually swallow it so that way it can work where it needs to work um otherwise they're complaining numb tongue or numb lips or something like that it's usually Rel to this um also kids getting into this can be bad it actually cause some pretty significant CS depression so it's why we try to keep it away from them if they can um other drugs where it says I do not cut or crush or chew it's usually related to the fact that they're long acting preparations and when chewing those you kind of break that preparation unless all the drug comes out at once so there's various reasons why we may recommend that next up is a prescription based product called Dex roran robotos and delum um this one's kind of interesting because one way you could treat cough is by actually giving opioids your opioid receptors will help to suppress cough tessive um but also you get like the analgesia aspect the Euphoria you get the the you know cess depressant aspects the addiction risk so we don't like to use opioids for cough in particular it's kind of like Overkill so what we have instead though is an agent that's actually related to the opioid Codine it's kind of like a chemical cousin and so by acting on these Sigma receptors they're able to decrease that cough response that cough you The receptors in the cough Center there and so typically found a lot of cough and cold preparations anytime I see like robotos being given um the question is always going to be like what else is included with that you know if I say someone has an overdose on NyQuil I'm always asking what's on the bottle because so many different products M contain Tylenol or in histamines or some decongestion or Dex with thoran so it's always good to question okay what's actually in the bottle you're dealing with because people just use the Brin names to broadly mean a whole lot of things there's like a Chris Rock sketch years ago we talked about as a mom every time they were sick they got rootes that's all they got and because it would kind of be a broad generalization okay this is what you get when you get a cough or cold these are for everything but traditionally use for cough what's interesting though is that in higher doses the reason why I include a picture of Bender the robot here is because it higher doses it kind of works as we'll call an nmda antagonist or glutamate antagonist in the brain and it can produce a pretty significant high they call it robot tripping for robotussin and so like I mentioned before I would not recommend doing this but because robotos can be bought off on in store shelves um you know usually see this in adolescents who have you know maybe more time than since and they will get bored and decide to use robot testin in order to get hies it's pretty harsh high from all I've encountered but you can see this even like in um patients taking like larger doses than maybe recommended or um you know kids AC getting into this you can see some of this like confusion agitation hallucinations maybe even seizures some rare cases so just be really cautious there and it also can interact with some of your um serotonergic medications like your medication for depression I don't want to get into serotonin syndrome too much right now but just suffices to say this can cause some interactions so we'll talk more about that behavioral health next semester uh next up is a mucolytic called guinin or an expectorant helps to loosen up mucus and make it easier to pass and so this will um just make it easier for patients to be able to cough stuff up and and get rid of that um so no big side effects to worry about with this one very well tolerated but the one thing I would recommend for sure is make sure they're drinking plenty of water because if they are dehydrated that also dehydrates the mucus in the lungs and so you want enough water there to be able to hydrate that mucus for them to be able to expectorate the mucus in the first place and again if they feel like they're producing more mucus than they were before they probably are because of the expectorant nature of the drug itself something that that's normal once it's gone it should help to reduce um further you know production of mucus in in the future there other mucs here's a couple of inhaled products that we'll use one called dornes Alpha this one is typically reserved for um patients with cystic fibrosis um they typically have very like thick tenacious mucus secretions that often times get infected and so this works to actually help to cleave a lot of the DNA bonds um that are within those nutrifil get attracted to that mucus there and so that helps to make it much easier for the patient to be to cough that stuff up to get rid of it to reduce pulmonary you know inflammation and infection risk there very expensive because it is an enzyme protein based drug here um that has been very useful for helping to clear infections uh reduce infections improvements and you know pulmonary function tests and all that good stuff for those uh particular patients there um more often we use as a mutic is is saline U basically if you think about normal saline normal meaning isotonic to our blood that is typically .9% 0.9% sodium chloride is normal this is using a hypertonic saline so like 7% saline for example what that'll do is is it actually will deposit all this extra salt into the mucus that then through osmosis will draw water into it to make it looser make it easier for patients to clear so really good for patients to have either like over production of this mucus or they're having like pulon issues they can't get rid of it very very helpful for that like my mom's had like a lot of lung issues um you know she always had so horrible and she coughed because you just have all this you just hear it you didn't need a stethoscope you just hear all the junk in her lungs um hypertonic saline help fix that almost immediately very very helpful this is an inhaled hypertonic saline another agent we could use as an inhal product um would be inal cysteine which interestingly is actually the antidote for Tylenol overdoses but when inhaled can actually help to hydrate and break up the mucus to make it again easier to pass here um the bad side about this though is that ocal cysteine has a ton of sulfur in it uh it's partly how it works to treat Tylenol poisoning um the problem with that is is it has a rotten egg smell to it and so as a result that may cause some intolerance some nausea vomiting related to that some patients may just outright refuse it because it's so gross Mellon to them rarely Broncos spasm but that's usually the biggest problems you're going to see from that standpoint anyway so that is covers it for the ENT section now what kind of questions can I answer for you all this moment hopefully my drawing skills are not too terrible for your purposes if no questions um enjoy your weekend hope you all had a wonderful we'll have a wonderful one enjoy it rest up get ready for next week whatever's going on next week the drawings help thank you I appreciate that I'm uh left-handed by Nature so I'm drawing with my right hand on a mouse and so they can look a little little gnarly sometimes yes thank you perona all right uh looks like no questions uh youall have a good one and I will talk to you soon bye