Hogan: Allergic Rhinitis Flashcards
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
(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
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
What happens to the airways of patients with asthma?
smooth muscle hypertrophy
basement membrane thickening
decreased lumen
mucus plugging
What are the immediate symptoms of allergic rhinitis?
itch - in nose, mouth, eyes, ears, throat anosmia rhinorrhea sneezing tearing eyes
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
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
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)
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)
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
6
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
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
What is the unified airway hypothesis?
allergic rhinitis and asthma are linked and should be considered a continuum of the same disease
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
What happens to asthma during puberty?
sometimes it improves during puberty, & then returns in adulthood
(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
What can be used to improve rhinitis and asthma symptoms in pts with both AR and asthma?
nasal steroids
Knowledge of (blank) are very relevant to ascertaining if rhinitis/asthma symptoms are potentially allergic.
local allergens
These are some common allergies in the inner city
cockroach
mice
This is a common allergy in the desert
swamp coolers –> indoor humidity –> mold
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
