Hogan > Pediatric Allergic Rhinitis & Asthma Flashcards
what is allergic rhinitis?
collection of sx from NOSE & EYES occurring when the pt inhales an allergen to which the pt is sensitized
T/F: sx of allergic rhinitis occur only late in the process
FALSE
occur early AND late
what are the hallmark features of allergic rhinitis?
itch or sneeze
what is asthma?
a chronic inflammatory disorder of the airways characterized by obstruction of airflow
can asthma be reversed?
yes
completely or partially w/ or w/o specific therapy
when does more than HALF of asthma develop?
before 3 yo
but it can happen at any age
what age group is having an asthma epidemic right now?
adults
T/F: multiple asthma triggers are possible, even in the same pt
TRUE
which sex is predominant in childhood and adult asthma?
child: male
adult: female
which cell types are involved in the early (asthma? allergy?) rxn?
tissue mast cells
peripheral blood basophils
which cell types are involved in the late rxn?
peripheral blood basophils only
what are the early phase mediators of inflammation?
congestion
sneezing
pruritis
secretions
what are the mediators of CELLULAR inflammation?
eosinophils
peripheral blood basophils
lymphocyte
neutrophils
what are the late phase mediators of inflammation?
congestion sneezing pruritis secretions (same as early)
how long does the early phase rxn take to kick in?
15-20 min
how long does the late phase rxn take to kick in?
4-6/8 hours
what cell is predominantly involved in the early phase?
mast cells
what cell is predominantly involved in the late phase?
eosinophils
what cell is predominantly involved in the chronic phase or repeated exposure?
lymphocytes
what occurs in the airway long-term in allergies/asthma?
airway remodeling
what are the immediate sx of allergic rhinitis?
itch (nose, mouth, eyes, throat, ears) anosmia rinorrhea sneezing tearing eyes
what are the late sx of rhinitis (after the allergen is inhaled)?
congestion coughing clogged/popping ears anosmia sore throat shiners fatigue/sleepy/malaise HA mouth breathing
what is the prevalence of allergic rhinitis in the US?
20%
what % of physician-dxed rhinitis pts have allergic rhinitis at all ages?
3-5.5%
what % of children have allergic rhinitis by 3 yo?
6%
what % of 13 yo children have allergic rhinitis?
44%
how bad are the sx of AR in the 13 yo pts who have 2 parents that have AR also?
1/2 have severe persistent sx
most had sx continuously for >2 mos/yr
about how many allergens are pediatric AR pts sensitized to?
3
when do the least amt of asthma sx occur?
summer
what is AR assoc w/ in the spring?
increased risk of uncontrolled asthma
what is uncontrolled asthma during autumn assoc w/?
presence of eczema
are children under 1 yo allergic to pollen?
nope
what is the trend of pollen allergy & age?
increasing #s of kids are allergic to pollen the older they get
what is the SINGLE most important predictive factor for incidence & persistence PAST PUBERTY for allergic rhinitis & asthma?
positive skin tests to outdoor allergens at baseline
T/F: asthma usu exists by itself
FALSE
what % of asthma pts have coexistent AR?
60-70%
T/F: most asthma pts have only lower airway disease
FALSE
lots have upper & lower
what is the unified airway hypothesis?
developmentally, the nose & lung occur together. Therefore, they share pathophysiologic pathways
what happens in allergic rhinitis pts if you give them nasal steroids?
improvement in BOTH rhinitis sx (expected) & bronchial reactivity/asthma sx scores
what do you need to know to ascertain if rhinitis/asthma sx are potentially allergic?
knowledge of local allergens
what allergens are linked to inner city asthma severity?
cockroach & mice
how do swamp coolers affect allergies?
if pts have swamp coolers, they are MORE LIKELY to be allergic to mold
why would a person have a swamp cooler?
they live in the desert > increases humidity
rural area pollen counts are (higher/lower) than urban, esp for grass, ash, hazel, & plantain
HIGHER
urban pollen counts are higher than rural for what?
ornamental trees
what is the functional way to ascertain IgE sensitization?
allergy skin testing
what is avoidance therapy?
removal of the allergen
if you can employ avoidance therapy with a pt, should you also prescribe meds?
probably not!
when should you start pharm therapy for allergic rhinitis?
PRIOR to the season w/ the pt’s allergen (bc once the mast cells get activated, AR/asthma is v hard to control)
what are the routes for AR meds?
liquid
pill
nasal spray
if you prescribe oral antihistamines & topical steroids & your pt is still not doing well, what can you do?
specifically identify the allergen in order to use avoidance therapy OR immunotherapy
what is the ONLY FDA approved immunomodulatory therapy that reduced fairly permanent tolerance?
allergy immunotherapy
what 2 things does immunotherapy reduce for asthma & allergies?
dec risk of AR progression to asthma in kids
dec risk of broadening allergic sensitization
what are the 2 forms of immunotherapy for AR/asthma?
SCIT & SLIT
what type of cells induce peripheral tolerance to allergens?
T reg cells
what skewing of T cells happens in immunotherapy?
skewing from allergen-specific effector T cells to regulatory
what do CD4+ CD25+ T reg cells control (generally) in immunotherapy?
allergen-specific immune response via suppressing various things
what 4 things do CD4+ CD25+ T reg cells suppress in immunotherapy?
- dendritic cells
- TH1, TH2, & TH17 effector cells
- allergen-specific IgE & IgG4 induction
- bone marrow-derived cells moving to tissues
what do CD4+ CD25+ T reg cells skew in immunotherapy?
dendritic cells towards IL-10 suppressor presentation
what are the 5 things to consider when prescribing meds for kids w/ allergic rhinoconjunctivitis?
- ease of use
- likeability
- cost
- side FX
- relevance to disease
what is the pathophysiology of asthma?
airway inflammation w/ bronchoconstriction
what cell types drive inflammation in kids & adults?
eosinophilic or neutrophilic
what most likely drives young childhood asthma?
viruses
what % of asthma has an allergic trigger?
70%
what are the main sx of asthma?
wheeze (expiratory>insp)
cough (worse at night)
chest tightness
SOB w/ colds/playing
what environmental things can exacerbate asthma sx?
allergens thunderstorms cold air laughing smoke pollen
T/F: the adult DDx list is the same as children when diagnosing asthma
FALSE
what are the 3 categories of wheezers?
- transient early
- non-atopic
- IgE-assoc
when do transient early wheezers peak?
0-3 yo
when do non-atopic wheezers peak?
3-6 yo
when do IgE-assoc wheezers/asthmatics peak?
6-11 yo & thru adulthood
what are the major criteria for the asthma predictive index in a wheezing child under 3?
- parent w/ asthma
- atopic dermatitis
- inhalant allergen sensitization
what is the asthma predictive index w/ persistent wheezing?
wheezing child <3yo has an increased risk of asthma if they have 1 MAJOR or 2 MINOR criteria
what are the minor criteria for the asthma predictive index in a wheezing child under 3?
- allergic rhinitis
- wheezing apart from colds
- eosinophils (4%+)
- food allergen sensitization
what is the significance of the FeNO measurement?
identifies eosinophilic inflammation (inc FeNO) > assesses whether chronic cough is d/t asthma or if asthma is controlled or not
how can FeNO help w/ drug decisions?
can help decide the start of a controller med or decreasing the amt of controller med
T/F: FeNO is standard for pts w/ asthma
FALSE
$$$$$ & not universally reimbursed, not in current asthma guidelines for controller meds
what is essential for evaluating the status of asthmatics?
pulmonary fxn testing 1-2x/yr
when can you start pulmonary fxn testing in asthmatic pts?
4-7 yo
what things increase the risk for needing therapy in asthma?
2+ oral steroid bursts/yr ER visits hospitalizations potentially fatal asthma poor PFTs
what are the categories & scoring of the asthma score?
each category is 0 1 or 2 0 is good, 2 is bad 1. pO2 2. cyanosis 3. insp airflow 4. accessory muscles 5. exp wheezing 6. CNS
what happens if your asthma score is >5?
impending respiratory failure
what happens if your asthma score is >7?
you are IN respiratory failure
what drugs can you use for acute ICU mgmt of asthma?
continuous albuterol neb
terbutaline IV or SQ
heliox
glucocorticosteroid
what 4 drugs can you use for maintenance/daily therapy?
inhaled steroids
leukotriene receptor antagonists
LABA
allergen avoidance
what can you use for acute mgmt/rescue drugs?
SABAs as needed or before exercise
what should you add to asthma mgmt if pt has steroid failure or seasonal issues?
LABA leukotriene antagonist theophylline anticholinergic-tiotropium roflumilast
