Asthma and Allergy Flashcards
Diagnosis suggested by typical symptoms in absence of URI or structural abnormality (nasal congestion/pruritus, worse at night with snoring, mouth-breathing;
watery, itchy eyes; postnasal drip with cough; possible wheezing; headache
AR
PE of AR
______—blue-gray-purple beneath lower eyelids;
often with ______—prominent symmetric skin folds
Allergic shiners (venous stasis)
Dennie lines
DDx for AR
– Nonallergic inflammatory rhinitis (no IgE antibodies)
– Vasomotor rhinitis (from physical stimuli)
– Nasal polyps (think of CF)
– Septal deviation
– Overuse of topical vasoconstrictors
Best dxtics for AR
In vivo—skin test (best):
° Use appropriate allergens for geographic area plus indoor allergens.
° May not be positive before two seasons
First gen antihistamine examples
First generation—diphenhydramine, chlorpheniramine, brompheniramine; cross blood-brain barrier—sedating
2nd gen antihistamine examples
Second generation (cetirizine, fexofenadine, loratadine)—nonsedating (now preferred drugs); easier dosing
Oral antihistamines are more effective than ____ but significantly less than intranasal steroids; efficacy ↑ when combined with an intranasal steroid
cromolyn
_______—most effective medication, but not first-line
Intranasal corticosteroids
° Least effective
° Very safe with prolonged use
° Best for preventing an unavoidable allergen
Chromones—cromolyn and nedocromil sodium:
Decongestants—(alpha-adrenergic → vasoconstriction)—topical forms (oxymetazoline, phenylephrine) ______ when discontinued
significant rebound
Administer gradual increase in dose of allergen mixture → decreases or eliminates person’s adverse response on subsequent natural exposure
Immunotherapy:
Major indication of immunotherapy
duration and severity of symptoms are disabling in spite
of routine treatment (for at least two consecutive seasons
treatment of choice for insect venom allergy.
Immunotherapy:
Immunotherapy: Should not be used for (lack of proof)
atopic dermatitis, food allergy, latex allergy, urticaria, children age <3 years (too many systemic symptoms
Complications of allergic rhinitis
– Chronic sinusitis – Asthma – Eustachian tube obstruction → middle ear effusion – Tonsil/adenoid hypertrophy – Emotional/psychological problems
Insect Venom Allergy due to what?
Hymenoptera (yellow jackets most notorious—aggressive, ground-dwelling, linger near food)
Diagnosis—for biting/stinging insects, must pursue ______
skin testing
Tx of stinging ang biting insects
Local—cold compresses, topical antipruritic, oral analgesic, systemic antihistamine; remove stingers by scraping
Indication for venom immune therapy—______
severe reaction with + skin tests (highly
effective in decreasing risk)
Most food allergies are—________
egg, milk, peanuts, nuts, fish, soy, wheat, but any
food may cause a food allergy.
________are most common cause of anaphylaxis seen in
emergency rooms
Food allergic reactions
With food allergies, there is an _______
IgE and/or a cell-mediated response
1/3 of children with atopic dermatitis have food allergies, but most common is ______
acute urticaria/ angioedema
Skin tests, IgE-specific allergens are useful for _____
IgE sensitization
A negative skin test excludes an IgE-mediated form, but because of cellmediated responses, may need a ___________
food elimination and challenge test in a controlled environment (best test)
Tx for food reactions
– Only validated treatment is elimination
– Epinephrine pens for possible anaphylaxis
Cause of Urticaria and Angioedema:
– Activation of mast cells in skin
– Systemically absorbed allergen: food, drugs, stinging venoms; with allergy, penetrates skin → hives (urticaria)
Acute, IgE-mediated (duration <6 weeks)
Cause of Urticaria and Angioedema:
– Radiocontrast agents
– Viral agents (especially EBV, hepatitis B)
– Opiates, NSAIDs
Non IgE-mediated, but stimulation of mast cells
Physical urticarias; environmental factors—
temperature, pressure, stroking, vibration,
light
Cause of Urticaria and Angioedema:
Autosomal dominant
– C1 esterase-inhibitor deficiency
– Recurrent episodes of nonpitting edema
Hereditary angioedema
IN Urticaria and Angioedema, If H1 antagonist alone does not work, H1 plus H2 antagonists are effective; consider
_______
steroids
For chronic refractory angioedema/urticaria → ______
IVIg or plasmapheresis
Sudden release of active mediators with cutaneous, respiratory, cardiovascular, gastrointestinal symptoms
Anaphylaxis
Most common reasons for Anaphylaxis in the hospital
In hospital—latex, antibiotics, IVIg (intravenous immunoglobulin), radiocontrast agents
Most common reasons for Anaphylaxis out of the hospital
food (most common is peanuts), insect sting, oral medications, idiopathic
What to do in the hospital for anaphylactic shock
Epinephrine IM (IV for severe hypotension); intravenous fluid expansion; H1 antagonist; corticosteroids; nebulized, short-acting beta-2 agonist (with respiratory symptoms); H2 antagonist (if oral allergen
Majority of patients with Atopic Dermatitis develop
allergic rhinitis and/or asthma
Patterns for skin reactions for Atopic dermatitis
° Acute: _______
° Subacute—_______
° Chronic—______
erythematous papules, intensely pruritic, serous exudate and excoriation
erythematous, excoriated, scaling papules
lichenification (thickening, darkening)
Distribution of AD
° Infancy: face, scalp,______
° Older, long-standing disease: _____
extensor surfaces of extremities
flexural aspects
Complications
– Secondary bacterial infection, especially _____
– Recurrent viral skin infections—________
most common
– Warts/molluscum contagiosum
S. aureus; increased incidence of T. rubrum, M. furfur
Kaposi varicelliform eruption (eczema herpeticum)
Types of Contact dermatitis
Irritant
Allergic
Types of Contact dermatitis
Results from prolonged or repetitive contact with various substances (e.g., diaper rash)
Irritant Contact Dermatitis
Types of Contact dermatitis
Delayed hypersensitivity reaction (type IV); provoked by antigen applied to skin surface
Allergic
Chronic inflammation of airways with episodic at least partially reversible airflow obstruction
ASTHMA
Two main patterns of BA:
Early childhood triggered primarily by_____
Chronic asthma associated with_____
common viral infections
allergies (often into adulthood; atopic
Gold standard for the Dx of BA =
spirometry during forced expiration. FEV1/FVC <0.8 = airflow obstruction (the forced expiratory volume in 1 second adjusted to the full expiratory lung volume, i.e., the forced vital capacity) in children age ≥ 5 yrs
Xray findings of BA
° Hyperinflation—flattening of the diaphragms
° Peribronchial thickening
BA
drug of choice for rescue and preventing exercise-induced asthma but inadequate control if need >1 canister/month
Short-acting beta-2 agonists: albuterol, levalbuterol (nebulized only), terbutaline, metaproterenol (rapid onset, may last 4–6 hrs;
mostly for added treatment of acute severe asthma in ED and hospital
Anticholinergics (much less potent than beta agonists): ipratropium bromide;
When to dc pts with BA exacerbations
Can go home if sustained improvement with normal physical findings and SaO2 >92% after 4 hours in room air; PEF ≥70% of personal best
