Emergency Measures in the Nurse’s Office: Asthma & Food Allergies

1. 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

2. Objectives: • Asthma • Definition/Pathophysiology • Triggers • Assessment • Treatment options • Food Allergies/Anaphylaxis • Definition/Pathophysiology • Triggers • Assessment • Treatment options • Preparation • Case Studies • Resources

3. 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 RespCritc Care Med, 2002

4. Characteristics of Asthma: • Airway inflammation – the lining of the airway becomes red, swollen, & narrow • Airway obstruction – muscles surrounding the airway constrict causing a reduction in air flow • Airway hyperresponsiveness – muscles surrounding the airway become twitchy and become overly sensitive to small amounts of allergens/irritants NHLBI, 2012

5. 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

6. 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

7. 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

8. Pathophysiology:

9. Pathophysiology: NHLBI, 2012

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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.

21. Controller Medications: • Single inhaled corticosteroids: • Alvesco • Asmanex • Flovent HFA/Diskus • PulmicortFlexhaler or respules for neb • QVAR

22. Controller Medications: • Combination Medications contain both ICS & LABA • Advair HFA/Diskus • (fluticasone/salmeterol) • Dulera HFA • (mometasonefuroate/formoterol) • Symbicort HFA • (budesonide/formoterol)

23. 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

24. 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.

25. 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

26. 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!

27. 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

28. 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

29. Food Allergies & Anaphylaxis

30. 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

31. 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

32. 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

33. 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

34. 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

37. 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

38. Symptoms: • Swelling • Trouble swallowing • Shortness of breath • Difficulty breathing or speaking • Hypotension • Loss of consciousness • Feeling of impending doom • Hives/erythema • Eczema flare • Pruritis • Nausea/vomiting/ diarrhea • Abdominal pain • Congestion/rhinitis/ sneezing/tearing • Cough/Wheeze

39. 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

40. What we must look for in kids: • 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 • 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

41. 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

42. 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

43. 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

44. Cutaneousreactions • Urticaria • Angioedema • Pruritis • Eczema flare • Erythema • Warmth • If limited to skin, generally not considered anaphylaxis

45. Mucus membranes • Eyes: tearing, redness, itch, swelling • Nose: rhinorrhea, itch, congestion, sneezing • Mouth: itch, swelling of lips, tongue or mouth

46. 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.

47. Lower airway • Bronchospasm • Shortness of breath • Rapid breathing • Cough • Wheeze • Retractions

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

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

50. 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.