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Cardiac and respiratory drugs: what physiotherapists need to know
Patients in every long case are on several medicines, and each one changes what you see and do: beta-blockers flatten the heart-rate response, diuretics cause postural dizziness, anticoagulants make percussion risky, a bronchodilator before airway clearance makes it work better. This page is organised by what the drug means for physiotherapy, not by pharmacology.
- Syllabus
- Ch 1(c) Cardiac and respiratory pharmacology
- Priority
- Foundation. Not asked on its own in 2016–2026; needed in every case answer and viva.
- Asked as
- Not asked 2016–2026
- Usual split
- Revision; viva questions
- Checked against
- Standard pharmacology references (BNF, Goodman and Gilman) and ACSM guidance on medications and exercise. Full list under Sources.
- Content checked
- 19 October 2026. Next review due October 2027.
- My revision
-
1Heart and blood-pressure drugs
| Group (examples) | What it does | Physiotherapy meaning |
|---|---|---|
| Beta-blockers (metoprolol, bisoprolol, atenolol, carvedilol) | Slow the heart and lower BP; reduce angina and arrhythmias | Lower resting and exercise heart rate: Karvonen targets overestimate, so use RPE and the talk test; fatigue; non-selective ones can trigger bronchospasm in asthma |
| ACE inhibitors and ARBs (ramipril, enalapril, losartan, telmisartan); sacubitril–valsartan | Lower BP; protect the heart and kidneys in heart failure and after MI | Postural and post-exercise hypotension: longer cool-down; dry cough with ACE inhibitors |
| Diuretics (furosemide, torsemide, spironolactone, hydrochlorothiazide) | Remove salt and water (heart failure, oedema, BP) | Dehydration, dizziness on standing, low potassium (cramps, arrhythmias); urgency: plan sessions after the morning dose has worked |
| Nitrates (glyceryl trinitrate spray or tablet under the tongue, isosorbide) | Widen veins and coronary arteries; relieve angina | Patient should carry GTN to sessions; take it sitting (it drops BP); headache; use before a known trigger if prescribed |
| Calcium-channel blockers (amlodipine; diltiazem, verapamil) | Widen arteries; diltiazem and verapamil also slow the heart | Ankle swelling (amlodipine), hypotension; slower heart-rate response (diltiazem, verapamil) |
| Antiplatelets (aspirin, clopidogrel, ticagrelor) | Stop platelets clumping; protect stents and grafts | Bruising and bleeding; never advise stopping them |
| Anticoagulants (heparin, enoxaparin, warfarin, apixaban, rivaroxaban, dabigatran) | Prevent or treat clots (DVT, PE, atrial fibrillation, mechanical valves) | Bleeding risk: gentle handling, care with percussion, suction and falls; check INR with warfarin (often 2–3; higher for mechanical valves) |
| Clot-dissolving drugs (streptokinase, tenecteplase, alteplase) | Dissolve the clot in STEMI, stroke, massive PE | High bleeding risk for the first day: no vigorous chest physiotherapy or injections |
| Statins (atorvastatin, rosuvastatin) | Lower LDL cholesterol; stabilise plaque | Muscle aches or weakness: report new unexplained muscle pain |
| Digoxin | Slows the rate in atrial fibrillation; mild boost to contraction | Toxicity (nausea, confusion, visual changes, slow or irregular pulse), especially with low potassium |
| Anti-arrhythmics (amiodarone) | Control atrial and ventricular arrhythmias | Slow heart rate; long-term lung fibrosis and thyroid problems (new breathlessness or cough) |
| Inotropes and vasopressors (dobutamine, noradrenaline, adrenaline) | Support BP and cardiac output in ICU | High or rising doses: no active mobilisation (see the ICU safety table) |
2Respiratory drugs
| Group (examples) | What it does | Physiotherapy meaning |
|---|---|---|
| Short-acting β2-agonists (salbutamol, levosalbutamol) | Quick relief of bronchospasm (reliever) | Give 15–30 minutes before airway clearance or exercise if prescribed; keep the reliever at hand; tremor and fast heart rate |
| Long-acting β2-agonists (salmeterol, formoterol) | 12–24-hour bronchodilation (with an inhaled steroid in asthma) | Not for sudden relief (except formoterol combinations in asthma, as prescribed) |
| Antimuscarinics (ipratropium short-acting; tiotropium, glycopyrronium long-acting) | Bronchodilation, less mucus secretion (mainly COPD) | Dry mouth; check inhaler technique |
| Inhaled corticosteroids (budesonide, fluticasone, beclometasone) | Reduce airway inflammation (asthma preventer; COPD with frequent exacerbations) | Rinse the mouth after use (thrush, hoarse voice); use a spacer |
| Oral steroids (prednisolone) | Treat exacerbations; some chronic diseases (ILD, sarcoidosis) | Long courses: osteoporosis (care with percussion and falls), muscle weakness, high sugar, thin skin, poor wound healing |
| Methylxanthines (theophylline, doxofylline) | Weak bronchodilator | Narrow safety margin: palpitations, nausea, tremor, seizures if levels are high |
| Leukotriene antagonists (montelukast) | Add-on in asthma and allergic rhinitis | Occasional mood or sleep changes |
| Mucoactive drugs (N-acetylcysteine, carbocisteine; hypertonic saline; dornase alfa in cystic fibrosis) | Thin or loosen sputum | Time airway clearance after them; hypertonic saline can cause bronchospasm, so give a bronchodilator first |
| Antibiotics (oral, IV, inhaled) | Treat infection | Inhaled antibiotics go after airway clearance, so they reach clear airways |
| Oxygen | A drug: corrects hypoxaemia | Prescribed with a target; see the oxygen card |
Usual order in cystic fibrosis and bronchiectasis: bronchodilator → mucoactive drug → airway clearance → inhaled antibiotic or steroid.
3Other drugs common in these patients
| Group (examples) | Physiotherapy meaning |
|---|---|
| Insulin and sulfonylureas (glimepiride, gliclazide) | Risk of low blood sugar during and hours after exercise: check sugar, carry glucose, avoid exercising at peak insulin action without food (see the diabetes page) |
| Metformin, gliptins, SGLT2 inhibitors (dapagliflozin, empagliflozin) | Low hypoglycaemia risk on their own; SGLT2 inhibitors also help heart failure but can cause dehydration |
| Anti-TB drugs (isoniazid, rifampicin, pyrazinamide, ethambutol) | Isoniazid: tingling and numbness of the feet (pyridoxine prevents it); rifampicin: orange urine and tears, many drug interactions; ethambutol: blurred vision; liver toxicity (jaundice, vomiting): report |
| Opioids and other painkillers (morphine, tramadol, paracetamol); epidurals and nerve blocks | Treat after the dose works (often 30–60 minutes after oral doses); opioids cause drowsiness, slow breathing, nausea and constipation; epidurals can cause leg weakness and low BP when sitting up |
| Sedatives and paralysing drugs (ICU) | No voluntary movement or cough under paralysis; daily sedation breaks are the time for active work |
| Anticholinesterases (pyridostigmine in myasthenia) | Treat when the dose is working (often about an hour after it); too much causes secretions and weakness |
4Timing physiotherapy around medicines
- Bronchodilator 15–30 minutes before airway clearance or exercise in reactive airways.
- Pain relief before post-operative chest physiotherapy and mobilisation.
- Insulin and meals: exercise 1–2 hours after a meal; check sugar before and after.
- GTN before a known angina trigger, if prescribed.
- Diuretics: after the morning dose has worked, so that toilet trips do not interrupt the session.
- Sedation in tetanus or ICU: coordinate with the nurse so the patient is comfortable but able to take part.
5Exam corner
Not asked on its own in the 20 papers (2016–2026). In long cases, a line on the drug's effect on your plan (for example "on beta-blockers, so intensity is set by RPE 11–13") shows clinical reasoning.
Test yourself
3 mHow do beta-blockers affect an exercise prescription?
They lower resting and peak heart rate, so heart-rate targets from formulas are too high; use RPE (11–13 or 12–16) and the talk test, or a heart rate from an exercise test done on the medicine.
MCQA patient with cystic fibrosis uses salbutamol, hypertonic saline and an inhaled antibiotic. The best order is:A. Antibiotic, airway clearance, saline, salbutamolB. Salbutamol, saline, airway clearance, antibioticC. Airway clearance, salbutamol, antibiotic, salineD. Saline, antibiotic, salbutamol, airway clearance
B. Open the airways, loosen the mucus, clear it, then deliver the antibiotic to clean airways.
MCQWhich drug most raises the bleeding risk of chest percussion?A. SalbutamolB. WarfarinC. AmlodipineD. Montelukast
B. Warfarin; check the INR and handle gently.
Sources
- MUHS BPTh syllabus (2012), CVR Ch 1(c).
- British National Formulary (BNF), current edition; Brunton LL, et al. Goodman and Gilman's The Pharmacological Basis of Therapeutics.
- American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription, appendix on common medications and their effects on exercise.
- Cystic Fibrosis Trust physiotherapy standards (2026) for the order of inhaled treatments.
Educational notes for exam preparation. Not medical advice. Never change a patient's medicines; report concerns to the doctor.
Version 1. Content checked 19 October 2026. Next review October 2027.