AI Asthma Allergy Flashcards by Rishi Chavan

Intermittent Asthma (step 1 care)

SABA alone

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Mild Persistent Asthma (step 2 care)

Low dose ICS first choice for all ages

alternatively Cromolyn or LTRA as monotherapy but ICS preffered

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Moderate Persistent Asthma (step 3 care) For 0-4 yr old

Increase the ICS to medium-dose range

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Moderate Persistent Asthma (step 3 care) For >5 yrs and older

Add a LABA to low dose ICS

alternatively, a LTRA can be added, but LABA more effective

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Moderate Persistent Asthma (step 4 care)

Medium dose ICS plus LABA (or LTRA)

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Severe Persistent Asthma (step 5 care)

High dose ICS plus LABA (or LTRA)

Consider Omalizumab if allergies >12yr old

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Severe Persistent Asthma (step 6 care)

High dose ICS plus LABA (or LTRA)

Oral CS

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Symptoms <=1x/year
Lung Function normal
Activity normal

Intermittent Asthma

{FEV1 >80%
FEV1/FVC >85%}

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Symptoms > 2x/week 
SABA use  > 2x/week 
Night walking 1-2{3-4}x/month
Orals CS >=2x/6months{year}
{FEV1 >80%
FEV1/FVC >80%} 
Activity minor interference

Mild Persistent Asthma

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Symptoms daily 
SABA use daily
Night walking 3-4x/month {> 1x/week} 
Orals CS >=2x/6months{year}
FEV1 60-80%
FEV1/FVC 75-80% 
Activity some limitation

Moderate Persistent Asthma

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Symptoms throughout day
SABA use several times/day
Night walking > 1x/week{nightly} 
Orals CS >=2x/6months{year}
FEV1 <75% 
Activity extremely limited

Severe Persistent Asthma

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When to start long-term control medication in children 0-4yr old who are well between exacerbations?

Orals CS >=2x/6months
Symptoms last >1day, Nightwalking >=4x/month
positive Asthma Predictive index

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positive Asthma predictive index

1 major or 2 minor
Major: Parental h/o asthma, physician dx atopic dermatitis
Minor: Allergen sensitization (skin testing), Blood Eosinopilia >4%, wheezing without a URI

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When to refer to an allergist or pulmonologist?

Moderate to Severe Persistent Asthma
Life-threatening episode
Poor control after 3-6 months of appr Rx
Need for further Dx testing or education
Unclear dx or complicated assoc cond.

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Coughing/SOB/chest pain 6-8 mins after starting exercise

Exercise induced Asthma

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EIA Rx

SABA 10 mins before exercise or

LABA or LTRA

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EIA dx

15% decrease in PEFR or FEV1 during exercise challenge

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laboratory Dx od Allergic Rhinitis (AR)

History history history PE
nasal smear for eosinophils best single test.
+ve if >10%eosinophils

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Mild AR

Oral 2nd gen antihistamines.

Can add oral decongestant as needed in older children

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Moderate to severe AR

Intranasal CS

if not tolerated use Montelukast (concurrent asthma) or oral / intranasal antihistamines

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allergy testing SENSITIZATION

Ag specific IgE can be demonstrated by testing

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allergy testing ALLERGY

causal relationship between exposure to allergen and clinical symptoms

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MC used skin test, safe, low cost, minimal discomfort, results in 15 mins, multiple Ags

Percutaneous (prick-puncture) method. Sensitive, more specific for aeroallergens but not food

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Skin test: painful, HR systemic reactions, more sensitive & reproducible, but less specific

Intradermal skin testing

Primary indication - venom sensitivity

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Positive skin test means

allergy is possible, needs conformation Sx after exposure

Negative skin testing means

can exclude allergy to specific antigen

Contraindications to skin testing Can do In Vitro testing for

HR of anaphylaxis (poorly controlled asthma, h/o severe reaction to minute exposure) Dernatographism, Urticaria, Mastocytosis, Atopic Dermatitis. Beta2 or ACE antagonist within 4 weeks of severe systemic reaction to allergen

Sensitivity, specificity & PPV >90% for common pollens (grass,trees); dustmites, cat allergens

In vitro testing | Results can be both qualitative and quantitative

egg, milk, peanut, tree nuts, and fish

CAP-RAST (in vitro) testing, when results greater than minimum value

Medications that should be stopped prior to skin testing

Antihistamines (3-7 days) H2 antagonists (2 days) TCAs (2 weeks) Omalizumab (6 months)

Medications that don't affect skin testing

oral and inhaled CS | Topically CS may partially suppress results

Less useful for venoms, weed pollens, latex, drugs and molds

In vitro skin testing

Environmental interventions to decrease dust mite allergen exposure

1. Remove carpets 2. Keep humidity below 50% 3. Wash bedding in hot water weekly 4. Encase mattresses in impermeable covers

Environmental interventions to decrease Indoor mold allergen exposure

decrease humidity, regular cleaning of surfaces with dilute bleach solution, use mold retardant paint, fix any water leaks, remove water damaged carpet

Cockroaches

Extermination Seal cracks in walls and floors, fix water leakage. Dont leave out food or garbage Air filtration not effective

Animal allergens

pet outdoor, or out of bedroom HEPA filter over forced air ducts in bedroom Remove carpeting in bedroom replace mattress and pillow covers. washing the pet twice weekly not realistic

outdoor pollens and molds

``` stay inside on dry, windy days don't hang laundry outside to dry brush pets if they are kept outside shower before bed keep windows closed, use AC ```

Honey bee cross react with

wasp venom

Immunotherapy not indicated in children with

only skin reactions

Not an indication for allergy testing in children or adults

a large local reaction (contiguous to skin site) | Sx peak by 48hrs & can last for upto a week, (nausea + fatigue)

with insect sting - intradermal skin test preferred over in-vitro tests because

of increased sensitivity

systemic cutaneous sx only <17 yrs old

no skin testing

systemic cutaneous sx only >=17 yrs old

Yes skin testing

Anaphlaxis

Yes skin testing

to rule out mastocytosis

serum tryptase 1-2 weeks after anaphylactic event

Local reactions can be treated with

ice and oral antihistamine | oral CS can be given if severe

Acute illness, skin findings AND respiratory compromise or reduced BP/Sx caused by reduced BP

Anaphylaxis or Anaphylactoid reactions.

Immediate IgE mediated hypersensitivity response to an allergen.

Anaphylaxis | Requires previous sensitization

Non IgE mediated. Stimulation of mast cells and basophils directly (hyperosmolar solution) or complement activation (immune complexes)

Anaphylactoid reaction. No role for desensitization.

Anaphylactoid reaction Triggers

exercise, cold,sunlight, RADIOCONTRAST, dyes, IVIG, transfusion reactions

Risk of reaction to radio contrast media can be decreased by

Pretreatment with steroids and H1/H2 antihistamines

Anaphylaxis or Anaphylactoid reactions. Dx

HnP, PE, | Serum tryptase measurement within 3 hrs of sx onset. (Not elevated in food-induced anaphylaxis)

Anaphylaxis or Anaphylactoid reactions.RX

IM Epi, O2 Albuterol, IV fluid boluses, vasopressors. If refractory hypotension = Glucagon observe for 2- 10 hrs in the ED (late phase) Refer AI

Insect allergies indications for self injectable EPI

>=17 yr previous systemic reaction (cutaneous or anaphylaxis) <16 yo previous anaphylaxis

Indications for Venom immunotherapy

Must have +ve skintest or immunoassay >=17 yr previous systemic reaction (cutaneous or anaphylaxis) <16 yo previous anaphylaxis

Venom intradermal (specific IgE testing) > skin testing. Who to test?

>=17 yr previous systemic reaction (cutaneous or anaphylaxis) <16 yo previous anaphylaxis

Not an Indications for Venom immunotherapy

large local reactions

severe vomiting, diarrhea, toxic appearance. below birthweight, dehydrated, acidotic, low albumin, increased WBC, heme positive stools. MethHbg?

Food protein induced enterocollitis syndrome | FPIES

Can be IgE mediated or Non IgE mediated (immunologically mediated)

Food allergy

Non immunological mediated (toxins, Lactase deficiency)

adverse reaction

Non IgE mediated

Food protein induced proctitis, FPIES, Dietary protein loosing enteropathy

IgE mediated food allergy infants

cow's milk, soy, egg, wheat

IgE mediated food allergy adolescents

peanut, treenuts, shellfish, fish

Sx isolated to lips, tongue, oropharynx:tingling, pruritis, occaisonal angioedema

Oral allergy syndrome - Immune crossreaction with specific food & environmental Ags

Birch tree and apple

Oral allergy syndrome - 2 % risk of anaphylactic reaction

ragweed and birch

Oral allergy syndrome - occurs in 30-40% children with allergic rhinitis

Oral allergy syndrome Mx

avoid specific foods known to cross-react

Blood streaked stools in an infant <3 months old, no frank diarrhea, no FTT

Food protein induced proctitis Rx switch to protein hydrolysate formula. BF moms to eliminate milk from their diet

Risk of severe reaction upon introducing the food, should not be done in clinic

FPIES

Negative skin testing wont rule out

FPIES as they are not IgE mediated