Hogan > Pediatric Allergic Rhinitis & Asthma Flashcards by Rhonda Mittenzwei

what is allergic rhinitis?

collection of sx from NOSE & EYES occurring when the pt inhales an allergen to which the pt is sensitized

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T/F: sx of allergic rhinitis occur only late in the process

FALSE

occur early AND late

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what are the hallmark features of allergic rhinitis?

itch or sneeze

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what is asthma?

a chronic inflammatory disorder of the airways characterized by obstruction of airflow

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can asthma be reversed?

yes

completely or partially w/ or w/o specific therapy

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when does more than HALF of asthma develop?

before 3 yo

but it can happen at any age

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what age group is having an asthma epidemic right now?

adults

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T/F: multiple asthma triggers are possible, even in the same pt

TRUE

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which sex is predominant in childhood and adult asthma?

child: male
adult: female

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which cell types are involved in the early (asthma? allergy?) rxn?

tissue mast cells

peripheral blood basophils

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which cell types are involved in the late rxn?

peripheral blood basophils only

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what are the early phase mediators of inflammation?

congestion
sneezing
pruritis
secretions

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what are the mediators of CELLULAR inflammation?

eosinophils
peripheral blood basophils
lymphocyte
neutrophils

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what are the late phase mediators of inflammation?

congestion
sneezing
pruritis
secretions 
(same as early)

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how long does the early phase rxn take to kick in?

15-20 min

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how long does the late phase rxn take to kick in?

4-6/8 hours

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what cell is predominantly involved in the early phase?

mast cells

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what cell is predominantly involved in the late phase?

eosinophils

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what cell is predominantly involved in the chronic phase or repeated exposure?

lymphocytes

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what occurs in the airway long-term in allergies/asthma?

airway remodeling

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what are the immediate sx of allergic rhinitis?

itch (nose, mouth, eyes, throat, ears)
anosmia
rinorrhea
sneezing
tearing eyes

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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

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what is the prevalence of allergic rhinitis in the US?

20%

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what % of physician-dxed rhinitis pts have allergic rhinitis at all ages?

3-5.5%

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what % of children have allergic rhinitis by 3 yo?

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?

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?

1. dendritic cells 2. TH1, TH2, & TH17 effector cells 3. allergen-specific IgE & IgG4 induction 4. 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?

1. ease of use 2. likeability 3. cost 4. side FX 5. 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?

1. transient early 2. non-atopic 3. 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?

1. parent w/ asthma 2. atopic dermatitis 3. 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?

1. allergic rhinitis 2. wheezing apart from colds 3. eosinophils (4%+) 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 ```