Transcript Asthma and Food Allergies in the School Setting

Emergency Measures in the Nurse’s
Office: Asthma & Food Allergies
Elisa Caracciolo, RN
The Children’s Hospital of Philadelphia
Division of Allergy and Immunology
March 29, 2014
Objectives:
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Asthma
Definition/Pathophysiology
Triggers
Assessment
Treatment options
Food Allergies/Anaphylaxis
Definition/Pathophysiology
Triggers
Assessment
Treatment options
III. Preparation
IV. Case Studies
V. 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:
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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:
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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
Assessment
Look, 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 Children
2-12 months
<50
1-5 yr
<40
6-8years
<30
9 + 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 triggers
Have students premedicate before exercise
Monitor 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 active
Peak 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:
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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 Devices
Recommend 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 reexposure.
• 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
•Swelling
• Eczema flare
•Trouble swallowing
• Pruritis
•Shortness of breath
• Nausea/vomiting/
diarrhea
•Difficulty breathing or
speaking
• Abdominal pain
•Hypotension
• Congestion/rhinitis/
sneezing/tearing
•Loss of consciousness
• Cough/Wheeze
•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
• It feels like there are
bugs in my ears
• My mouth itches or tingles
• My tongue feels
bumpy
• My mouth/throat feels
funny
• Something is stuck in my
throat
• My tongue feels
tight/heavy
• 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 Dx
Careful clinical evaluation is necessary to rule out
conditions that may mimic anaphylaxis:
Arrhythmia
Myocardial infarction
Aspiration
Pulmonary Embolism
Vasovagal syncope
Systemic
mastocytosis
Scromboid (fish)
poisoning
Pneumothorax
Status asthmaticus
Seizure
Stroke
Hypoglycemia
Hereditary
angioedema
Serum sickness
Carcinoid syndrome
Pheochromocytoma
Ott, 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
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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
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Bronchospasm
Shortness of breath
Rapid breathing
Cough
Wheeze
Retractions
Gastrointestinal
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Vomiting
Nausea
Diarrhea
Abdominal pain/cramps
CNS
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Anxiety
Agitation
Loss of consciousness
Feeling of impending doom
Confusion
Cardiovascular
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Weak pulse
Hypotension/Tachycardia
Loss of consciousness
Cyanosis/Pallor
Dizziness
Lightheadedness
Cardiovascular collapse and hypotensive shock are lifethreatening.
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
Epinephrine
Epinephrine 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 needed
20% acute cases need multiple doses
Epinephrine
• Side effects may include:
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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 place
Store medications in an easily accessible location
Check expiration dates (and window on epinephrine)
regularly
Train delegates to administer epinephrine
 Obtain history
Determine if symptoms are consistent with
anaphylaxis
Administer epinephrine/antihistamine per doctor’s
orders
Call 911 - even if symptoms improve
Contact 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:
o Milk allergy
o Asthma- well-controlled
o Allergic Rhinoconjunctivitis
o Eczema- 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 cough
and 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:
o American Academy of Allergy, Asthma and
Immunology (AAAAI)
o American College of Allergy, Asthma and
Immunology (ACAAI)
o Food Allergy Resource & Education (FARE)
o Kids with Food Allergies
o National Institute of Allergy and Infectious Disease
(NIAID)
Contact info:
• Elisa Caracciolo, RN
Division of Allergy & Immunology
Email: [email protected]
Phone: 856-435-1300 x 31379
Questions??