Emergency Measures in the Nurse’s Office: Asthma & Food AllergiesElisa Caracciolo, RNThe Children’s Hospital of PhiladelphiaDivision of Allergy and Immunology

March 29, 2014

Objectives:I. Asthma• Definition/Pathophysiology• Triggers• Assessment• Treatment options

II. Food Allergies/Anaphylaxis• Definition/Pathophysiology• Triggers• Assessment • Treatment options

III. PreparationIV. Case StudiesV. Resources

Asthma 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 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, 2002

Characteristics of Asthma:

1) Airway inflammation – the lining of the airway becomes red, swollen, & narrow

2) Airway obstruction – muscles surrounding the airway constrict causing a reduction in air flow

3) Airway hyperresponsiveness – muscles surrounding the airway become twitchy and become overly sensitive to small amounts of allergens/irritants

NHLBI, 2012

Facts About Asthma:• Affects more than 6 million children

• Most children develop 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, 2013

Pathophysiology of Asthma:

•Stimuli activate inflammatory cells: mast cells, macrophages, eosinophils, T-lymphocytes

• Inflammatory mediators are released and migrate to the airway causing activation of neutrophils, eosinophils, lymphocytes, and monocytes

NIH.gov, 1995

Pathophysiology:•Mediators cause epithelial damage,

smooth muscle contraction, mucus secretion, swelling, & hyperresponsiveness

•Hyperresponsiveness causes further airway obstruction and leads to symptoms of acute asthma exacerbation

NIH.gov, 1995

Pathophysiology:

Pathophysiology:

NHLBI, 2012

Common Triggers:•Environmental allergens: pollen, mold, dust

mites, pet dander, cockroaches

•Colds and viral respiratory infections (predictor for developing asthma)

•Exercise

•Changes in weather/temperature

• Irritants: smoke, air pollution, paints, perfumes, cleaning agents AAAAI, 2013

Risk factors for developing childhood asthma:

•Allergies•Family history•Frequent respiratory infections•Low birth weight•Second hand smoke •Low socioeconomic status•Urban environment•Obesity

NIH.gov, 1995

Risk 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 problems

NIH.gov, 1995

Symptoms 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 sports

NIH.gov, 1995

Signs 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/pallor

Assessment For acute asthma attacks perform

assessment and remain with the patient!

Obtain vital signs: HR, RR, Pulse ox & temperature

Perform visual assessment and chest exam

Continuous pulse ox if less than 95% (if capable)

Call 911 for any signs of respiratory distress and continue observation until help arrives

AssessmentLook, Listen, & Feel

for……….. Wheezing (inspiratory, expiratory,

absent) Work of breathing Retractions Grunting Posturing Nasal flaring Decreased aeration Alterations in Mental

Status Changes in vital signs

Guide to RR in Awake Children2-12 months <501-5 yr <406-8years <309 + years <25

NIH.gov

Treatment Beta2 agonist (rescue medication)

• Albuterol inhaler (Proair,Ventolin,Proventil)▫ 2 puffs with spacer q 4 hours as needed

• Albuterol nebulizer solution (2.5mg/3mL premixed)▫ 1 vial in nebulizer q 4 hours as needed

• Levalbuterol inhaler (Xopenex)▫ 2 puffs with spacer q 4 hours as needed

• Levalbuterol (Xopenex) nebulizer solution (0.31mg, 0.63mg, 1.25mg)▫ 1 vial in nebulizer q 4 hours as needed

If symptoms do not improve in 15 minutes – repeat quick relief.If symptoms still do not improve after quick relief is repeated – call 911

Treatment• Administer oxygen if available while waiting for

EMS (some NJ schools have standing orders for O2)

• It is important to recognize early warning signs of asthma episodes and initiate prompt treatment to prevent severe airway narrowing

• If rescue medications are unavailable and child’s condition is declining, call 911

Prevention:Prevention is KEY!Avoid triggersHave students premedicate before exerciseMonitor peak flows (if available) although this

should not replace your assessment of the patient. Peak flows less than 20% of predicted/best levels

might be an indication that asthma is activePeak flows less than 50% - immediate action

necessary. Give rescue, if peak flow/sx do not improve may need to call 911.

Prevention:• Children with known diagnosis of asthma are

usually on maintenance therapy at home.

• Anti-inflammatory medications are given daily to control airway inflammation.

• These medications are listed in the “Green Zone” on the asthma care plan. During flares, these medications are sometimes increased to help prevent the need for oral steroids.

• Occasionally children may need short bursts of oral steroids to control severe flares.

Controller Medications:•Single inhaled corticosteroids:

▫Alvesco▫Asmanex▫Flovent HFA/Diskus▫Pulmicort Flexhaler or respules for neb▫QVAR

Controller Medications:•Combination Medications contain both ICS

& LABA▫Advair HFA/Diskus

(fluticasone/salmeterol)▫Dulera HFA

(mometasone furoate/formoterol)▫Symbicort HFA

(budesonide/formoterol)

Spacer DevicesRecommend the use of spacer and mask for younger children or mouthpiece for older children to assist with delivery of inhaled medications.

Figure A shows medication deposited in mouth and esophagus without using spacer

Figure B shows medication delivered mostly to lungs with spacer use

Controller Medications:•Singulair (montelukast)

*preferred in our population

•Accolate (zafirlukast)

These medications are not as effective as ICS and many times are used in combination with other therapies.

Asthma at school•Many times school nurses and teachers

recognize symptoms of undiagnosed asthma

•Recognize the subtle signs: ▫Excessive fatigue at school (asthma could be

keeping child up at night)▫Unable to keep up or chooses not to

participate in sports/activities▫Missing a lot of school

Asthma at school•Children with asthma should be able to

sleep, learn, & play!!!

• If you notice signs of uncontrolled asthma – notify parents and encourage family to follow-up with specialist

•Goals for initiating or adjusting maintenance therapy include: no symptoms between flares, no limits in physical activity, fewer & easier control of flares, sleeping at night, fewer absences!

Asthma at school•Young children may not be able to articulate

when they are experiencing symptoms▫Is the child fussy? responding normally to

stimulation?▫Is the child refusing food or drink?▫Changes in speech or quality of voice?

• In addition to using assessment and observation skills, work with families to find out specific triggers and their child’s way of expressing symptoms

Adolescents & Teens•Need more frequent reminders to take their

maintenance meds

•Allow them to take inhalers without a lot of attention

•Discuss importance of avoiding triggers especially SMOKE!

•May need reminders to pretreat and warm-up before exercise

Food Allergies & Anaphylaxis

Food Allergies/Anaphylaxis•Food allergy is an abnormal response to a food

protein that is triggered by the immune system.

•An allergen is an antigenic substance which can produce an immediate hypersensitivity reaction through prior sensitization on subsequent re-exposure.

•Anaphylaxis is an acute, potentially life threatening allergic reaction caused by linkage of the relevant allergen to effector cells of the immune system by previously formed antigen specific IgE.

FARE, 2013. AAAAI, 2014

Facts About Food Allergies:•Affect approximately 15 million people

including 1 in 13 children

•Eight foods account for 90 % of all reactions: milk, egg, soy, peanut, tree nuts, wheat, fish & shellfish

FARE, 2013. AAAAI, 2014

Facts About Food Allergies:•Symptoms range from mild to severe and can

affect the skin, GI tract, respiratory and cardiovascular systems

•Symptoms usually appear within minutes to a few hours after ingesting the food

•Fatal reactions can occur with exposure to any food allergen, but most fatalities have been associated with age, mostly teens, delayed administration of epinephrine, and co-morbid asthma.

AAAAI, 2013

Pathophysiology:

Patients with food allergies produce IgE antibodies to specific food proteins. These antibodies bind to IgE receptors on circulating basophils and mast cells in the body, including in the skin, gastrointestinal tract, and respiratory tract.

AAAAI ,2013

Pathophysiology:•Subsequent allergen exposure binds and

cross links IgE antibodies on the cell surface, resulting in receptor activation and initiates the release of inflammatory mediators (eg. histamine) and begins the allergic cascade.

•The release of mediators cause vasodilatation, smooth muscle contraction, and mucus secretion all of which contribute to the symptoms noted on the next few slides.

AAAAI, 2013

Food Allergy Diagnosis:•Food specific IgE testing (blood test) is

used for screening but may not confirm allergy

•Skin testing – most common method for screening for food allergies. Negative predictive value >90%, Positive predictive value <50 %.

•Because skin and blood test are not perfect, oral food challenges are necessary to confirm the presence of specific food allergy

JACI, 2010

Symptoms:• Hives/erythema

• Eczema flare

• Pruritis

• Nausea/vomiting/ diarrhea

• Abdominal pain

• Congestion/rhinitis/ sneezing/tearing

• Cough/Wheeze

•Swelling

•Trouble swallowing

•Shortness of breath

•Difficulty breathing or speaking

•Hypotension

•Loss of consciousness

•Feeling of impending doom

Symptom 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.

• 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 Guidelines

What we must look for in kids:• My tongue is hot or

burning

• My mouth itches or tingles

• My mouth/throat feels funny

• 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 behavior

Anaphylaxis involves:•A systemic response to an allergen.

•A dysfunction 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 Guidelines

Differential DxCareful clinical evaluation is necessary to rule out conditions that may mimic anaphylaxis:

ArrhythmiaMyocardial infarctionAspirationPulmonary EmbolismVasovagal syncopeSystemic mastocytosisScromboid (fish) poisoningPneumothorax

Status asthmaticusSeizureStrokeHypoglycemiaHereditary angioedemaSerum sicknessCarcinoid syndromePheochromocytomaOtt, 2014 from JACI Practice Parameter,

2010

Assessment:• 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, 2014 from Simons & Camargo, 2012

Cutaneous reactions• Urticaria• Angioedema• Pruritis• Eczema flare• Erythema• Warmth

• If limited to skin, generally not considered anaphylaxis

Mucus membranes•Eyes: tearing, redness, itch, swelling

•Nose: rhinorrhea, itch, congestion, sneezing

•Mouth: itch, swelling of lips, tongue or mouth

Upper 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•Retractions

Gastrointestinal•Vomiting•Nausea•Diarrhea•Abdominal pain/cramps

CNS•Anxiety•Agitation•Loss of consciousness•Feeling of impending doom•Confusion

Cardiovascular• Weak pulse• Hypotension/Tachycardia• Loss of consciousness• Cyanosis/Pallor• Dizziness• Lightheadedness

Cardiovascular collapse and hypotensive shock are life-threatening.

Bradycardia is rare and may be due to a vasovagal response.

Treatment: Drug of choice = epinephrine

Epinephrine works to counteract vasodilation and hypotension by producing vasoconstriction

Has bronchodilator effects to reduce airway edema and bronchoconstriction

Down regulates release of histamine, tryptase and other inflammatory mediators

EpinephrineEpinephrine autoinjector dosage< 25 kg (55lbs) = 0.15mg >25 kg (55lbs) = 0.3 mg

Epipen/Epipen Jr

Auvi-Q

Generic

Epinephrine•Epinephrine should be given IM in

anterolateral aspect of thigh•Hold for 10 seconds (Epipen & generic)•Hold for 5 seconds (Auvi-Q)•Call 911•Because it is rapidly metabolized can be repeated in 5-15 min if needed20% acute cases need multiple doses

Epinephrine•Side effects may include:

▫Tachycardia▫Palpitations▫Hypertension ▫Headache▫Shakiness▫Dizziness▫Nausea/Vomiting▫Sweating

These effects are usually transient and benefit outweighs risk

Antihistamines•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/Xopenex – 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 discharge, 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 consciousness Brain: anxiety, agitation, or loss of consciousness

Symptom/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, but 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?To be prepared: Have written response plan in placeStore medications in an 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 doctor’s

ordersCall 911 - even if symptoms improveContact parents

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 notified teacher and was brought to

the nurse’s office

Ott, 2014

Case 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 milk in 2008.

Ott, 2014

Case 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, legs

Treatment??

Ott, 2014

Case Studies:Case study # 1•10 minutes after Benadryl, starts with tight coughand lip edema

Physical Exam:•General: Crying•HEENT: Conjunctival erythema; perioral

edema•Lungs: Wheezing throughout, tight cough•Derm: Hives persist Ott, 2014

Case Studies:Case Study # 2 8 year old healthy boy Presents to the nurse’s 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 2 days

Case Studies:Case Study # 2 Past Medical History:

Asthma: dx age 4, well controlled, viral induced, currently prescribed maintenance ICS

Allergic Rhinitis Drug Allergy: PCN

Last flare was in January with URI No recent hospitalizations or oral steroids

Case Studies:Case Study # 2•Vital Signs normal•Lungs: dry cough with mild expiratory

wheeze b/l•Derm: generalized erythema and

scattered hives on areas where skin exposed to air

•Patient is sitting down and leaning forward•Peak flow: normal calculated = 300 •Current peak flow: 210

•Treatment???

Case Studies:Case Study # 2 10 minutes after administering albuterol:

Wheezing has resolved Breath sounds slightly decreased at the

bases Intermittent cough Peak flow now = 240 Patient resting comfortably Hives are starting to resolve, but

erythematous areas still present on hands, neck and cheeks

What next?

Resources:oAmerican Academy of Allergy, Asthma and

Immunology (AAAAI)oAmerican College of Allergy, Asthma and

Immunology (ACAAI)oFood Allergy Resource & Education (FARE)oKids with Food AllergiesoNational Institute of Allergy and Infectious

Disease (NIAID)

Contact info:•Elisa Caracciolo, RN Division of Allergy & ImmunologyEmail: caraccioloe@email.chop.eduPhone: 856-435-1300 x 31379

Questions??