emergency measures in the nurse’s office: asthma & food allergies elisa caracciolo, rn the...
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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
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 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 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.
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
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 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: [email protected]: 856-435-1300 x 31379