11.2 Respiratory Pharmacotherapy

The current FNP-BC Test Content Outline lists respiratory among the official drug-agent classes. Domain III Planning asks whether you chose an evidence-based regimen; Domain IV Implementation asks whether the dose, device, interaction, and counseling are safe. This is the prescribing chapter that sits on top of the diagnoses in Section 11.1.

GINA 2025/2026: no more SABA-only asthma care

For adolescents and adults, GINA’s core rule is simple enough to quote on a test: every patient receives ICS-containing therapy. SABA-only treatment is not preferred. As-needed albuterol without an anti-inflammatory reliever or a daily ICS leaves airway inflammation untreated, is linked to more exacerbations, and is the outdated pattern the exam still uses as a foil.

Track 1 is preferred. The reliever is ICS-formoterol (an anti-inflammatory reliever). Steps 1–2 use as-needed ICS-formoterol only — no mandatory daily maintenance if symptoms are infrequent. Step 3 is low-dose MART (maintenance-and-reliever therapy): the same ICS-formoterol inhaler is taken every day and used for relief. Step 4 is medium-dose MART. Step 5 (add-on LAMA, phenotype-guided biologic referral, consideration of higher-dose ICS-formoterol) is usually comanagement, not a first FNP solo move.

Track 2 is the alternative when Track 1 is not available or not accepted: daily ICS or ICS-LABA maintenance, with a SABA or ICS-SABA reliever. Track 2 still forbids SABA as the only drug. If you use a SABA reliever, there must be an ICS in the plan — either daily or in the reliever combination.

MART only works with a fast-onset LABA that is approved for relief — in practice, formoterol. You cannot tell a patient to use maintenance fluticasone-salmeterol “as a rescue puff.” Salmeterol is too slow and is not a reliever. Write the device, the as-needed ceiling, and the action-plan yellow zone so the patient does not invent a second, SABA-only inhaler that undoes the strategy.

COPD pharmacotherapy: GOLD in one page

After spirometry confirms obstruction, GOLD ABE drives the first maintenance inhaler. Group A (few symptoms, rare exacerbations) can start with a bronchodilator. Groups B and E are built on LAMA/LABA dual long-acting bronchodilation as the foundation — not an inhaled steroid first and not a standing SABA as “the COPD inhaler.” Add ICS when blood eosinophils are high or exacerbations keep happening (especially hospitalizations) despite dual bronchodilation. Low eosinophils make ICS less useful and raise pneumonia risk without much benefit. Smoking cessation is disease-modifying; no inhaler replaces it. Long-term oxygen is for chronic severe hypoxemia and needs specialty confirmation of the saturation/PaO2 criteria and a safe home plan — do not send a concentrator home from a single clinic spot-check of 91% in a patient who just walked in from the parking lot.

A SABA still has a role as true rescue for sudden bronchospasm in COPD and as a clinic nebulizer during an exacerbation. It is not controller therapy. Combining four controllers without reviewing technique is how frail adults end up on a DPI they cannot inhale.

ICS, LABA, LAMA, and why the device matters

Inhaled corticosteroids treat eosinophilic airway inflammation. They are the backbone of asthma control and a targeted add-on in COPD. Local harms are thrush and dysphonia — rinse and spit after ICS, and use a spacer with many MDIs. High-dose, long-duration ICS can affect bone, skin, eyes, and the adrenal axis, but that risk is still smaller than repeated systemic steroid courses. Do not “protect the bones” by stopping ICS in a pregnant or poorly controlled asthmatic (Section 11.3).

ICS-LABA combinations are Track 2 maintenance and the usual COPD add when ICS is indicated. Never prescribe LABA monotherapy for asthma — that is a safety error, not a style difference. LAMA (tiotropium and class peers) is COPD foundation therapy and an add-on in severe asthma. Watch for dry mouth, urinary retention, and glaucoma symptoms in older men with prostatic hypertrophy.

SABA (albuterol, levalbuterol) relaxes smooth muscle within minutes. Teach it as rescue or as the Track 2 reliever paired with ICS, not as a lifestyle. Using a canister every few weeks is a control problem; using one every few days is an exacerbation or a Step-up signal. Prime MDIs, shake MDIs, and do not shake most DPIs. Slow deep inhalation for MDI; fast deep inhalation for DPI. Recheck technique at every respiratory visit. If the patient cannot coordinate an MDI, add a spacer or change the device. Writing “albuterol 2 puffs q4h prn” without naming the device and watching a demonstration is an incomplete prescription.

Montelukast, oral steroids, and inhaled versus systemic

Leukotriene receptor antagonists — montelukast is the one you will see — can help allergic rhinitis plus asthma, exercise-induced symptoms, and aspirin-exacerbated respiratory disease. They are not preferred standalone controllers and they do not replace ICS at GINA Step 3. Teach the boxed warning: montelukast is associated with serious neuropsychiatric events — agitation, depression, sleep disturbance, and suicidal thinking. Counsel every patient (and parent) before the first fill, stop the drug if mood or behavior changes, and do not start it casually because “the child hates inhalers.” Fix the device and the action plan first.

Systemic corticosteroids are for exacerbations and for a few steroid-responsive rare diseases, not for monthly “tune-ups.” Adult asthma or COPD exacerbation courses are short (often about five days of prednisone in the 40–50 mg range for many adults; pediatric weight-based bursts follow local/NAEPP-style practice). Short bursts usually do not need a taper. Recheck why the patient needed the third burst this year — that is a controller and trigger problem, not a reason to leave them on 10 mg daily from the primary-care bottle. Inhaled steroid treats day-to-day inflammation with a fraction of the systemic exposure; oral steroid treats the flare. Do not substitute a dexamethasone injection for a missing ICS inhaler in chronic asthma.

Antibiotics for outpatient pneumonia — and influenza timing

For outpatient adult CAP, follow current IDSA adult outpatient options and local pneumococcal macrolide resistance. In many previously healthy outpatients that means high-dose amoxicillin or doxycycline. A macrolide is reasonable only when local macrolide resistance is known to be low. Do not give azithromycin automatically. Patients with comorbidities often need a beta-lactam plus a macrolide or doxycycline, or a respiratory fluoroquinolone reserved for when other options fail or are contraindicated — fluoroquinolones carry FDA warnings (tendon, aortic, hypoglycemia, CNS) that make them a considered choice, not a default z-pack substitute. Duration is often about five days if the patient is clinically stable; longer automatic courses are not a virtue. Bronchitis without pneumonia still does not get an antibiotic.

Oseltamivir (and other approved influenza antivirals) help most when started within 48 hours of symptom onset. Treat high-risk outpatients and anyone sick enough to need hospital care even if the clock has run past 48 hours; do not withhold treatment from a day-three pregnant patient or a hypoxic older adult because a handout said “only 48 hours.” Oseltamivir does not replace influenza vaccination and it does not treat bacterial pneumonia. If influenza is in the differential and the patient is eligible, start the antiviral; do not wait for a send-out that returns after the treatment window.

FNP traps: refilling albuterol without an ICS-containing plan; using salmeterol as a MART reliever; adding montelukast to avoid an inhaler teaching visit; treating COPD with ICS monotherapy; writing azithromycin for every infiltrate and every winter cough; and starting home oxygen or a 21-day steroid taper because the last clinic did it. Prescribe the class that matches the guideline track, then watch the patient use the device.