Asthma and Food Allergies in the School Setting

1、Emergency Measures in the Nurses Office: Asthma & Food AllergiesElisa Caracciolo, RNThe Childrens Hospital of PhiladelphiaDivision of Allergy and ImmunologyMarch 29, 2014Objectives:I.AsthmaDefinition/PathophysiologyTriggersAssessmentTreatment optionsII.Food Allergies/AnaphylaxisDefinition/Pathophysi

2、ologyTriggersAssessment Treatment optionsIII. PreparationIV. Case StudiesV.ResourcesAsthma defined: Chronic lung disease that causes inflammation and narrowing of the airways Causes recurring episodes of wheezing, chest tightness, shortness of breath, and coughing that most often occurs at night or

3、early in the morning (decreased endogenous serum cortisol levels) Excess mucus production and muscle spasms cause decreased airflow AAAAI, 2013; AM J Resp Critc Care Med, 2002Characteristics of Asthma:1) Airway inflammation the lining of the airway becomes red, swollen, & narrow2) Airway obstruction

4、 muscles surrounding the airway constrict causing a reduction in air flow3) Airway hyperresponsiveness muscles surrounding the airway become twitchy and become overly sensitive to small amounts of allergens/irritantsNHLBI, 2012Facts About Asthma: Affects more than 6 million children Most children de

5、velop asthma before age 5 Number 1 reason in the United States for children missing school Leading cause of pediatric emergency room visits No cure but with management can live normal active lives!AAAAI, 2013Pathophysiology of Asthma: Stimuli activate inflammatory cells: mast cells, macrophages, eos

6、inophils, T-lymphocytes Inflammatory mediators are released and migrate to the airway causing activation of neutrophils, eosinophils, lymphocytes, and monocytes NIH.gov, 1995Pathophysiology: Mediators cause epithelial damage, smooth muscle contraction, mucus secretion, swelling, & hyperresponsivenes

7、s Hyperresponsiveness causes further airway obstruction and leads to symptoms of acute asthma exacerbationNIH.gov, 1995Pathophysiology:Pathophysiology: NHLBI, 2012Common Triggers: Environmental allergens: pollen, mold, dust mites, pet dander, cockroaches Colds and viral respiratory infections (predi

8、ctor for developing asthma) Exercise Changes in weather/temperature Irritants: smoke, air pollution, paints, perfumes, cleaning agentsAAAAI, 2013Risk factors for developing childhood asthma: Allergies Family history Frequent respiratory infections Low birth weight Second hand smoke Low socioeconomic

9、 status Urban environment ObesityNIH.gov, 1995Risk factors for asthma related deaths: Age 17-24 and over 55 African American especially between 15-44 yrs of age Previous life threatening asthma episode Hospital admission in past year Poor medical management Psychological or psychosocial problemsNIH.

10、gov, 1995Symptoms of acute exacerbation: Coughing Wheezing may be absent Breathlessness while walking or while at rest Increased respiratory rate Chest tightness Chest or abdominal pain Fatigue, feeling out of breath Agitation Increased pulse rate Inability to participate in sportsNIH.gov, 1995Signs

11、 of worsening condition: Inability to walk or talk in complete sentences Retractions increased use of chest, neck or abdominal muscles Refusal to lie down a child may prefer to sit or lean forward in order to make breathing easier Changes is color cyanosis/pallorAssessmentv For acute asthma attacks

12、perform assessment and remain with the patient!Obtain vital signs: HR, RR, Pulse ox & temperaturePerform visual assessment and chest examContinuous pulse ox if less than 95% (if capable)Call 911 for any signs of respiratory distress and continue observation until help arrivesAssessmentLook, Listen,

13、& Feel for.Wheezing (inspiratory, expiratory, absent)Work of breathingRetractionsGruntingPosturingNasal flaringDecreased aerationAlterations in Mental StatusChanges in vital signsGuide to RR in Awake Children2-12 months501-5 yr406-8years309 + years90%, Positive predictive value 50 %. Because skin an

14、d blood test are not perfect, oral food challenges are necessary to confirm the presence of specific food allergyJACI, 2010Symptoms: Hives/erythema Eczema flare Pruritis Nausea/vomiting/ diarrhea Abdominal pain Congestion/rhinitis/ sneezing/tearing Cough/WheezeSwelling Trouble swallowingShortness of

15、 breathDifficulty breathing or speakingHypotensionLoss of consciousnessFeeling of impending doomSymptom timing: Usually occurs within the first half hour of ingestion but can vary from seconds to hours depending on dose, length of exposure, and sensitivity of patient. Mostly occurs as a single event

16、. May have a biphasic reaction symptoms recur several hours after the initial reaction. May be protracted symptoms may persist for several hours despite treatment.CHOP Anaphylaxis GuidelinesWhat we must look for in kids: My tongue is hot or burning My mouth itches or tingles My mouth/throat feels fu

17、nny Something is stuck in my throat My tongue feels tight/heavy It feels like there are bugs in my ears My tongue feels bumpy In very young children look for: pulling or scratching at tongue or ears, drooling, changes in voice or behaviorAnaphylaxis involves: A systemic response to an allergen. A dy

18、sfunction in at least 1 major target organ. Distinct signs of mast cell activation: hives, pruritis, flushing, angioedema, wheeze, hypotension. Prior history of exposure to the allergen. Detection of allergen-specific IgE.CHOP Anaphylaxis GuidelinesDifferential DxCareful clinical evaluation is neces

19、sary to rule out conditions that may mimic anaphylaxis:ArrhythmiaMyocardial infarctionAspirationPulmonary EmbolismVasovagal syncopeSystemic mastocytosisScromboid (fish) poisoningPneumothoraxStatus asthmaticusSeizureStrokeHypoglycemiaHereditary angioedemaSerum sicknessCarcinoid syndromePheochromocyto

20、maOtt, 2014 from JACI Practice Parameter, 2010Assessment: Anaphylaxis is usually diagnosed by clinical presentation an history. Skin reactions occur in 90% of patients. GI symptoms appear in 30-40% cases of anaphylaxis. Lower respiratory involvement in 50-60%. Hypotension occurs in about 30%.Ott, 20

21、14 from Simons & Camargo, 2012Cutaneous reactions Urticaria Angioedema Pruritis Eczema flare Erythema Warmth If limited to skin, generally not considered anaphylaxisMucus membranes Eyes: tearing, redness, itch, swelling Nose: rhinorrhea, itch, congestion, sneezing Mouth: itch, swelling of lips, tong

22、ue or mouthUpper airway Tightness Trouble speaking Trouble breathing Edema of larynx or epiglottis can cause upper airway obstruction. This may present as subtle discomfort in throat or can be stridor or respiratory distress.Lower airway Bronchospasm Shortness of breath Rapid breathing Cough Wheeze

23、RetractionsGastrointestinal Vomiting Nausea Diarrhea Abdominal pain/crampsCNS Anxiety Agitation Loss of consciousness Feeling of impending doom ConfusionCardiovascular Weak pulse Hypotension/Tachycardia Loss of consciousness Cyanosis/Pallor Dizziness LightheadednessCardiovascular collapse and hypote

24、nsive shock are life-threatening.Bradycardia is rare and may be due to a vasovagal response.Treatment:v Drug of choice = epinephrineEpinephrine works to counteract vasodilation and hypotension by producing vasoconstrictionHas bronchodilator effects to reduce airway edema and bronchoconstrictionDown

25、regulates release of histamine, tryptase and other inflammatory mediatorsEpinephrineEpinephrine autoinjector dosage25 kg (55lbs) = 0.3 mgEpipen/Epipen JrAuvi-QGeneric Epinephrine Epinephrine should be given IM in anterolateral aspect of thigh Hold for 10 seconds (Epipen & generic) Hold for 5 seconds

26、 (Auvi-Q) Call 911 Because it is rapidly metabolized can be repeated in 5-15 min if needed20% acute cases need multiple dosesEpinephrine Side effects may include: Tachycardia Palpitations Hypertension Headache Shakiness Dizziness Nausea/Vomiting SweatingThese effects are usually transient and benefi

27、t outweighs riskAntihistamines H1 Blockers: First Generation: Benadryl (diphenhydramine) 1mg/kg q 6 hours Max dose = 50 mg Second Generation: Zyrtec (cetirizine)Second generation antihistamines are equally effective, have a longer duration of action, and are less sedating.Bronchodilators Albuterol/X

28、openex used as adjunctive therapy Should NEVER replace epinephrine!Beta agonist may be helpful for respiratory symptoms after epinephrine is given.Symptom/Treatment Review: Skin: “hives” (red blotches or welts that itch), mild swelling, severe swelling Eyes: tearing, redness, itch Nose: clear discha

29、rge, itch, congestion Mouth: itch; lip swelling; tongue swelling Throat: tightness, trouble speaking, trouble breathing in Lungs: shortness of breath, rapid breathing, cough, wheeze Gut: repeated vomiting, nausea, abdominal pain, diarrhea (usually later) Heart/Circulation: weak pulse, loss of consci

30、ousness Brain: anxiety, agitation, or loss of consciousnessSymptom/Treatment Review: Symptoms in bold are signs of severe allergic reaction/anaphylaxis and epinephrine should be administered immediately. If patient has ONLY mild hives or skin swelling antihistamine (diphenhydramine) may be given, bu

31、t should watch closely for progression. If more than 2 systems are involved give epinephrine.Are you prepared?Delays in recognition of symptoms or administration of epinephrine can result in fatal outcomes. Are you prepared?vTo be prepared: Have written response plan in placeStore medications in an

32、easily accessible locationCheck expiration dates (and window on epinephrine) regularlyTrain delegates to administer epinephrine Obtain historyDetermine if symptoms are consistent with anaphylaxisAdminister epinephrine/antihistamine per doctors ordersCall 911 - even if symptoms improveContact parents

33、Non IgE mediated allergies Food Protein Induced Enterocoloitis (FPIES) Eosinophilic Esophagitis (EoE)Case Studies:Case # 1 10 year old healthy boy Accidentally exposed to “milk” free cupcake at lunch. Icing contained milk. Complained of mouth itching and stomach pain. Ingested 20 minutes ago. Child

34、notified teacher and was brought to the nurses officeOtt, 2014Case Studies:Case study # 1 Past Medical History: oMilk allergyoAsthma- well-controlledoAllergic RhinoconjunctivitisoEczema- mild Diagnosed as a baby. Had positive skin testing and family strictly avoids milk. History of anaphylaxis to mi

35、lk in 2008.Ott, 2014Case Studies:Case Study # 1 Vital Signs normal General: Occasionally scratching ENT: No changes Lungs: Clear bilaterally Derm: Dry skin, erythematous large hives, back bilateral arms, legsTreatment?Ott, 2014Case Studies:Case study # 1 10 minutes after Benadryl, starts with tight

36、coughand lip edemaPhysical Exam: General: Crying HEENT: Conjunctival erythema; perioral edema Lungs: Wheezing throughout, tight cough Derm: Hives persist Ott, 2014Case Studies:Case Study # 2 8 year old healthy boy Presents to the nurses office with shortness of breath & mild dry sounding cough He is able to speak in complete sentences, but tells you that he just ran outside during gym class and his chest feels funny. Upon assessment he tells you he forgot to take his Flovent for the past