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BLOCK 9; Week 4-M > Pediatric Allergic Rhinitis & Asthma > Flashcards

Pediatric Allergic Rhinitis & Asthma Flashcards

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1
Q

What is allergic rhinitis?

A

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.

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2
Q

What is asthma? What distinguishes this from COPD?

A

Asthma is a chronic inflammatory disorder of the airways characterized by obstruction of airflow
may be completely or partially reversed with or without specific therapy

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3
Q

More than half of asthmatics develop before what age?

A

before 3 yo

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4
Q

T/F Each patient only has one trigger.

A

False. Multiple triggers possible in same patient.

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5
Q

Which gender makes up most of childhood asthma cases? Adult asthma cases?

A

males–children

females–adult onset

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6
Q

What happens in an allergic response?

A

mast cells activated by allergen & release histamine, triptase.
Get sneezing, itch, congestion, secretions.
IL-5 recruits eosinophils, basophils, neutrophils. They release more mediators, including leukotrienes.
Get more congestion, sneezing, secretions.

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7
Q

What happens during the early phase of allergen exposure?

A

After inhalation of allergen into the lung. The early phase of asthma is initiated by allergen binding to specific IgE on mast cells. Histamine release occurs and bronchoconstriction follows. Cellular cytokines are released during this early phase event.
FEV1 decreases, get congestion.

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8
Q

What happens during the late phase of an allergic airway response?

A

The late phase is initiated by influx of eosinophils responding to mast cell released cytokine signals. A second drop in FEV1 occurs several hours after initial allergen exposure.
**this phase can be dangerous if a kid was exposed to a cat & sneezed & then several hours later needed to be rushed to the ER.

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9
Q

What occurs in the chronic phase of an airway response to an allergen?

A

With continual exposure to allergen comes frequent drop in pulmonary function and ongoing symptoms. In addition to eosinophils, lymphocyte participate in inflammatory response.

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10
Q

What are some of the things that occur during airway inflammation?

A 
airway edema
secretions
smooth muscle hypertrophy if chronic.
Basement membrane thickening. 
Mucus plugging.
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11
Q

What are the immediate symptoms of allergic rhinitis?

A 
Itch can occur in the nose, mouth, eyes, throat, ears
Anosmia
Rhinorrhea
Sneezing
Tearing eyes
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12
Q

What are the late rhinitis symptoms after allergen is inhaled?

A 
Congestion
Coughing
Clogged / popping ears
Anosmia
Sore throat
Shiners
Fatigue/Sleepiness/Malaise
Headache
Mouth breathing
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13
Q

What is the #1 cause of missed work days?

A

allergic rhinitis

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14
Q

What is the differential diagnosis for allergic rhinitis in children?

A 
Sinusitis
Adenoidal hypertrophy
Anatomic nasal variations
Cystic Fibrosis (polyps)
Immotile Cilia
Tic Cough-can be confused w/ tourrette's
Non Allergic Rhinitis-temp, dryness, non IGE mediated.
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15
Q

When you see polyps in nose in children…what do you think? In adults?

A

Adults–allergic rhinitis

Kids–worry about cystic fibrosis. Must get a sweat test.

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16
Q

What happens to the sleep of children w/ rhinitis?

A

can develop sleep apnea

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17
Q

What are some complications of allergic rhinitis?

A 
Sinusitis
Vernal Conjunctivitis-can get vision loss
Recurrent OM
Eustachian tube dysfunction
Worsening AD
Worsening asthma
Sleep apnea  (adenoidal obstruction)
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18
Q

What is vernal conjunctivitis?

A

present w/ photophobia
sticky mucus threads in b/w the cobbling of their palpebral conjunctiva

can get vision loss

when you see photophobia + allergic rhinitis–>think about this.

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19
Q

What is the prevalence of allergic rhinitis?

A

20%

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20
Q

**About 6% of children have allergic rhinitis by what age?

A

age 3!!!

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21
Q

**What happens to children w/ 2 parents with allergic rhinitis?

A

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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22
Q

**what is polysensitization?

A

3 aeroallergens or more. Most peds patients are allergic to 3 or more.

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23
Q

**What % of AR kids are allergic to only perennial aeroallergens (mold, cat etc)?

A

1/4

can encounter these things throughout the year.

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24
Q

T/F Most patients with AR are sensitized to pollen.

A

True.

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25
Q

**What part of the year are asthma symptoms the lowest?

A

summer

parents sometimes take kids off maintenance meds & then they have bad attacks in fall & are hospitalized.

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26
Q

**___ associated w/ increase in risk of uncontrolled asthma during the spring.

A

allergic rhinitis

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27
Q

**presence of ____ associated w/ higher risk of uncontrolled asthma during fall?

A

eczema

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28
Q

What ages do you see pollen allergies develop?

A

t develop it w/ your first season of exposure.

1/2 kids 3-4 yo have this allergy.

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29
Q

What is predictive of adult patient w/ allergy to hay, pollen etc?

A

positive skin tests to outdoor allergens at baseline.

even if this disappears at puberty–>will come back roaring in adulthood.

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30
Q

There is a strong connection b/w allergic rhinitis & -______.

A

asthma!

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31
Q

What should patients with AR & asthma be treated with?

A

nasal glucocorticosteroids

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32
Q

What are some common allergens in rural/inner city areas?

A

cockroaches

mice

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33
Q

East coast w/ hurricane season has what major allergen problem?

A

MOLD!!

dust mite allergy

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34
Q

How could a patient in the desert of Nevada have a bad mold & dust mite allergy?

A

those living with swamp coolers!

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35
Q

What are the rural pollen allergy problems?

A

grass, ash, hazel, plantain, whatever plants/trees are deciduous

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36
Q

What are the urban pollen problems?

A

not the deciduous trees, but the planted trees. ornamental trees.

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37
Q

T/F Lack of redness & itch on allergy testing doesn’t necessarily rule out that allergen.

A

FALSE. No mast cell response–no redness/itch–no allergy.

38
Q

What is the most important part of allergy therapy?

A

avoidance therapy–get rid of the cat.

39
Q

When should allergy medications begin for allergic rhinitis?

A

before the season of allergies

b/c once the mast cells are activated, difficult to control.

40
Q

WHat forms do medications for allergic rhinitis come in?

A

liquid
pill
nasal spray

41
Q

Easter
Memorial Day
Labor Day
What are the allergens @ each of these seasons?

A

Easter-tree season
Memorial Day–grass season
Labor Day–weed season

42
Q

What are some important antihistamines?

A 
cetirizine
fexofenadine
loratidine
diphenhydramine
hydroxyzine
azelastine nasal spray
43
Q

What do you need to know about cetirizine?

A 
OTC & cheap
allergic rhinitis & allergic conjunctivitis 
once daily
rare sedation
syrup or tab
44
Q

What do you need to know about fexofenadine?

A

OTC
allergic rhinitis & allergic conjunctivitis
1-2 times/day
no sedation–doesn’t cross BBB, good for kids w/ behavioral problems
oral suspension or dissolving tab

45
Q

What is the pro & con w/ loratidine?

A

pro: non sedating
con: not as effective

46
Q

What is the problem w/ diphenhydramine?

A

SEDATION

and need to take 6X/day for continuous relief

47
Q

HOw often do you need to take hydroxyzine? Is it sedating?

A

less sedation than benadryl

4X/day

48
Q

What is important to know about azelastine nasal spray?

A

1 puff in nose2X/day
tastes terrible!!!
could cause a nosebleed

49
Q

When a child has an eye problem w/ allergies…what is the best route of delivery ?

A

NOSE! Kids hate stuff in their eyes.

50
Q

What is cromolyn?

A

good for allergic rhinitis
OTC
pretreatment.
nasal spray

51
Q

T/F You can use Montelukast, leukotriene receptor antagonist, to treat AR and asthma.

A

True. 1X/day

52
Q

What are the steroid options for AR?

A

intranasal steroids
fluticasone
Princess nose spray b/c it smells good.

53
Q

What’s awesome about allergy immunotherapy?

A

Allergy Immunotherapy is the only immunomodulatory therapy which is FDA approved AND induces fairly permanent tolerance.
Reduces risk of developing asthma in AR children by 40%.
Reduces risk of broadening allergic sensitization further.

54
Q

What are the 2 forms of immunotherapy for allergies? What are the pros/cons?

A

SCIT: greater risk for anaphylaxis
SLIT: covers one allergen

55
Q

Slide 51

A

X

56
Q

Slide51

A

X

57
Q

Slide 51

A

X

58
Q

Eosinophilic & neutrophilic inflammation exists in what age group of asthma? Viral driven?

A

Children/adults–eosinophils/neutrophils

Young children-viral

59
Q

As your child grows the likelihood of allergy being the cause of asthma increases/decreases?

A

increases

probably an allergic trigger to the asthma attack.

60
Q

What are the symptoms of asthma?

A 
wheezing--expiration>inspiration
cough w/ exertion or sleep
chest tightness
SOB w/ exertion
allergens, thunderstorms, cold air, laughing, smoke exposure increases
61
Q

Spirometry improvement from baseline of >____% after ___ use for asthma diagnosis.

A

> 10-12% w/ SABA use

62
Q

What are alternative diagnoses to consider w/ children who you think may have asthma?

A

Consider in alternate diagnosis in children: foreign object, rings, vocal cord dysfunction, CF, BPD, CHF. Particularly if first episode or unilateral.

63
Q

What are alternative diagnoses to consider w/ adults who you suspect to have asthma?

A

Consider CHF, Foreign object, COPD, Smoking, CVID, alpha-1 antitrypsin deficiency, Lung Cancer in adults/ geriatrics

64
Q

Which age group has the highest prevalence of transient early wheezers? non-atopic wheezers? Ig-E associated wheeze/asthma?

A

Transient–0-3
Non-atopic: 3-6
IgE: climbs across age groups, more common in older children & adults

65
Q

THe wheezing child <3 yo has increased risk of asthma if they meet which major criterion?

A

at least 1
parent w/ asthma
atopic dermatitis
inhalent allergen sensitization

66
Q

THe wheezing child <3 yo has increased risk of asthma if they meet which 2 minor criteria?

A 
at least 2 
allergic rhinitis
wheezing apart from colds
eosinophilia
food allergen sensitization
67
Q

What is the major evidence of obstruction in an asthma patient?

A

FEF25-75, really see pattern of expiration; see decreased in asthma.

68
Q

What is FeNO measurement used for?

A

identifies eosinophilic inflammation
see if asthma is controlled by meds.
exhaled breath condensate of fractional exhaled nitric oxide.
if low FeNO, pretty well controlled

69
Q

Give the major spirit of asthma diagnosis.

A

airway obstruction reversible w/ bronchodilator

do flow volume loops at least 1-2/year

70
Q

When do you say–this kid is a high risk asthma patient?

A 
2 or more oral steroid bursts/year
ER visits
Hospitalizations
Potentially Fatal Asthma  (ICU stay or intubation).
Poor PFTs
71
Q

What are ways to assess how well controlled the asthma is?

A 
cough?
wheeze?
SOB?
frequency of symptoms?
attacks/albuterol use? 
PFTs?
72
Q

What makes you run to an asthma patient?

A

silent chest
no inspiratory or expiratory wheezing…things have progressed negatively
look for PO2, cyanosis, insp airflow & exp wheezing, accessory muscle use, CNS

73
Q

What meds do you use w/ acute asthma management in ICU?

A

continuous albuterol nebulization
terbutaline IV or subcu
heliox–decreases turbulent flow in the airways, more laminar & efficient route to the alveoli

74
Q

What is the rescue management for asthma?

A

beta agonists, SABA

75
Q

What is the long term medical management of asthma?

A

inhaled steroids
leukotriene receptor antagonists
LABA
allergen avoidance

76
Q

What might be a good treatment option for mild asthmatics, particularly kids?

A

episodic inhaled glucocorticosteroid

77
Q

What are good drugs to add on to asthma management?

A

LABA
leukotriene antagonist
theophylline-neutrophilic asthma, steroid sparing
anticholinergic-tiotropium
roflumilast (PDE inhibitor)-neutrophilic asthma, prob not for children.

78
Q

Step management

A

https://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

79
Q

How do you assess severity?

A

frequency of symptoms, more than or less than 2 days/week
nighttime awakening: under or over 2X/month
lung function: more or less than 80%
steroid use/burst: more or less than 2X/year, can affect growth

80
Q

How do you assess control?

A 
symptoms occurrence
nighttime awakenings
interference w/ normal activities
SABA
Lung Function, FEV1
oral steroid bursts
side effects from meds
81
Q

Steps 1-6; management?

A

Step 1-SABA
Step 2-Low dose ICS
Step 3-Medium dose ICS
Step 4-Medium dose ICS + LABA or Montelukast
Step 5-High dose ICS + LABA or Montelukast
Step 6-High dose ICS + lABA or montelukast OR oral corticosteroids, omalizumab.

82
Q

Big risk for omalizumab?

A

anaphylaxis.

83
Q

What are indications for consulting an allergist for an asthmatic patient?

A

over 400 micrograms of inhaled steroid per day

hospitalization

84
Q

What is a moderate dose of corticosteroids?

A

400 micrograms.

85
Q

What MUST you know about prescribing LABA?

A

LABA alone is considered malpractice for a child. COPD drug, can’t be an individual component.
must be in a combination mix w/ an inhaled steroid.

doesn’t address inflammation & down regulates beta receptors, can lead to death if used unopposed.

86
Q

T/F Unopposed continuous albuterol is a bad idea.

A

True.

87
Q

Cromolyn works how?

A

anti-inflammatory
weak
4X/day

88
Q

Is theophylline used in the hospital?

A

no, b/c takes too long to use IV

need to check levels b/c it can cause hypokalemia, arrhythmias, seizures

89
Q

When should ipratropium be used?

A

ipratropium is useful in ER to prevent ICU stays

not effective in nebulizer at home

90
Q

Can you use epinephrine to treat a severe asthma attack?

A

yes. but it only seems to be effective for up to 3 doses.

BLOCK 9; Week 4-M (8 decks)

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