Hogan: Allergic Rhinitis Flashcards by Megan Foggia

Collection of symptoms from the nose and eyes occurring when the individual inhales an allergen to which he is sensitized. Symptoms may occur both early and late. A hallmark feature is itch or sneeze.

allergic rhinitis

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(blank) is a chronic inflammatory disorder of the airways characterized by obstruction of airflow
may be completely or partially (blank) with or without specific therapy.
At any age. In more than half of asthmatics-develops before (blank) years old. But now adult epidemic is being appreciated.
Multiple triggers are possible even in same patient.
(blank) predominate in children, females in adult onset asthma

asthma;
reversed;
3;
males

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What cells are involved in the early phase of asthma caused by a specific allergen? What cells are involved in the late phase? In the chronic phase?

mast cells - allergen binds to cross-linked IgE on mast cells –> histamine is released (minutes)

late phase - flux of eosinophils in response to mast cell cytokine signals (4-8 hours)

chronic phase - with repeated exposure, it becomes a cell mediated reaction with lymphocytes

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What happens to the airways of patients with asthma?

smooth muscle hypertrophy
basement membrane thickening
decreased lumen
mucus plugging

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What are the immediate symptoms of allergic rhinitis?

itch - in nose, mouth, eyes, ears, throat
anosmia
rhinorrhea
sneezing 
tearing eyes

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What are the later symptoms of allergic rhinitis - after the allergen is inhaled?

congestion
coughing
clogged/popping ears (eustachian tube dysfunction) 
anosmia
sore throat
fatigue/sleepiness
headache
mouth breathing

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What are some physical exam findings in asthma patients?

shiners under eyes
hang-dog lips (dry from mouth breathing)
allergic crease on nose
blue/pale nasal mucosa
allergic conjunctivitis

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What is the differential diagnosis for children with symptoms of allergic rhinitis?

sinusitis
adenoidal hypertrophy
anatomic nasal variations
CF (polyps are CF unless proven otherwise)
immotile cilia
tic cough
non allergic rhinitis (ex: skiing and nose starts running)

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What are the complications of allergic rhinitis?

Sinusitis
Vernal Conjunctivitis (photophobia)
Recurrent otitis media
Eustachian tube dysfunction
Worsening eczema
Worsening asthma
Sleep apnea  (adenoidal obstruction)

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About (blank)% of children have AR by 3 years of age.

44 % of 13 year old children with AR (2 parents with AR)

*Half had severe persistent symptoms
*Vast majority had symptoms continuously >2 months/year

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What is the mean number of allergens that pediatric patients with AR are sensitized to?

about 3 (polysensitized)

**most pts are likely to have symptoms year-round bc they encounter different antigens across the year

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How does asthma change seasonally? In which season are there the lowest asthma symptoms? In which season is there an increased risk of uncontrolled asthma with AR? During which season is eczema associated with higher risk of uncontrolled asthma?

summer;
spring;
autumn

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What is the unified airway hypothesis?

allergic rhinitis and asthma are linked and should be considered a continuum of the same disease

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What happens to the prevalence of pollen allergy as children get older?

it increases

**0% pollen allergy if less than 1 yo
need exposure to the allergen

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What happens to asthma during puberty?

sometimes it improves during puberty, & then returns in adulthood

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(blank) first symptoms of both AR and asthma occur in 1st yr. of symptoms vs. (blank) had AR first then asthma

1/3;

2/3

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What can be used to improve rhinitis and asthma symptoms in pts with both AR and asthma?

nasal steroids

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Knowledge of (blank) are very relevant to ascertaining if rhinitis/asthma symptoms are potentially allergic.

local allergens

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These are some common allergies in the inner city

cockroach

mice

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This is a common allergy in the desert

swamp coolers –> indoor humidity –> mold

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People living in rural areas generally allergic to these things

grass
ash
hazel
plantain

People living in urban areas general allergic to these things

ornamental plants

A functional way to ascertain IgE sensitization

allergy testing

**look for redness & itch

This should be done before prescribing allergy meds to kids

avoidance therapy

**remove allergen!

When should you begin allergy medications?

prior to the season **once mast cells are activated, the asthma/AR is way more difficult to get under control **Easter - tree season Memorial day - grass season Labor day - ragweed season

Common antihistamine for allergic rhinitis - rare sedation - once daily

Cetirizine

Another antihistamine - no sedation (doesn't cross BBB) - up to two times daily - this is Allegra

Fexofenadine

This antihistamine is terrible for allergies, but is super common in the household - must take it 6x per day

Diphenhydramine

Put up the nose - tastes disgusting - very effective - also improves allergic conjunctivitis

Azelastine nasal spray

These things can be used for allergic conjunctivits specifically

cromolyn ophthalmic soln olopatadine ophthalmic soln ketotifen soln **eye drops

Anti-inflammatory -- best used for pretreatment

Cromolyn

Leukotriene receptor antagonist - AR and asthma - once daily

Montelukast

Topical steroid given intranasally - smells like roses

Fluticasone

If your patient fails oral antihistamine/topical steroids, what should you do?

send em for an allergy consult

This can be used to prevent allergies - comes in two formats - sublingual vs subcutaneous

allergy immunotherapy **inject multiple allergens

What kind of immune reaction is occuring when you use allergy immunotherapy

basically produce T regs to allergen

Eosinophilic or neutrophilic inflammation exists in children and adults. Younger children more likely (blank) driven.

viral

Allergic or non-allergic possible as infant, but as child is older increasing likelihood of (blank) until 8 then approximately 70% of asthma has an allergic trigger.

allergy

How does asthma present?

Wheezing. (Lack of wheeze doesn’t exclude asthma.) Expiratory wheeze may worsen to include inspiration. Small children E>I on exam. Cough (Worse at night or play.) Chest tightness (“elephant sits on chest”) Difficulty breathing with colds or play (wheeze, tight, cough, SOB). **symptoms worse with allergens, thunderstorms, cold air, laughing, smoke exposure or pollen season

What is the spirometry definition of asthma?

FEV1 improves by 10-12% after short acting beta agonist

Other diagnoses to consider with asthma symptoms

``` children: foreign object vocal cord dysfunction CF CHF ``` ``` adults: CHF foreign body COPD smoking lung cancer ```

These factors make a child at greater risk for asthma if less than 3 yo

1 of the following: parent w asthma atopic dermattis inhalant allergen sensitization ``` 2 of the following: AR wheezing apart from colds eosinophilia food allergen sensitization ```

What happens to the following in asthma? FVC FEV1 FEF (25-75) MVV

all decrease **if FEV1/FVC decreases (less than 1), think obstructive

``` Important for the diagnosis of asthma Airway obstruction reversible with bronchodilator Essential for following all asthmatics flow volume loop at least 1-2 per year Can start at age 4-7 years ```

pulmonary function testing

Factors used in asthma score at acute presentation. What score = respiratory failure?

``` pO2 cyanosis inspiratory airflow accessory muscles expiratory airflow CNS ``` 5+ means impending resp failure 7 = resp failure

Used as a drip in ER for acute ICU management of asthma exacerbation

terbutaline Heliox (increases laminar flow thru alveoli) give a steroid to try and control edema, etc

Choices for the outpatient control of pediatric asthma

inhaled steroids leukotriene receptor antagonists long-acting beta agonist allergen avoidance **rescue w albuterol as needed

If you have failure with inhaled steroids, what should you use?

long-acting beta agonists leukotriene antagonist theophylline **steer clear anticholinergic-tiotropium (for asthma/COPD mix - more for adults as of right now)

Should you use a long acting beta agonist as monotherapy in children?

no!!! Ex: mix Flucticasone w Salmeterol

Bad effects of theophylline

hypokalemia nausea vomiting seizures

Anti-cholinergic used for severe status asthmaticus in children

Ipratropium **used inpatient, not at home

Why isn't epi really used anymore to treat asthma attacks?

now we do continuous albuterol instead