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

Pediatric Allergic Rhinitis & Asthma Flashcards

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
**What part of the year are asthma symptoms the lowest?
summer | parents sometimes take kids off maintenance meds & then they have bad attacks in fall & are hospitalized.
26
**___ associated w/ increase in risk of uncontrolled asthma during the spring.
allergic rhinitis
27
**presence of ____ associated w/ higher risk of uncontrolled asthma during fall?
eczema
28
What ages do you see pollen allergies develop?
t develop it w/ your first season of exposure. | 1/2 kids 3-4 yo have this allergy.
29
What is predictive of adult patient w/ allergy to hay, pollen etc?
positive skin tests to outdoor allergens at baseline. | even if this disappears at puberty-->will come back roaring in adulthood.
30
There is a strong connection b/w allergic rhinitis & -______.
asthma!
31
What should patients with AR & asthma be treated with?
nasal glucocorticosteroids
32
What are some common allergens in rural/inner city areas?
cockroaches | mice
33
East coast w/ hurricane season has what major allergen problem?
MOLD!! | dust mite allergy
34
How could a patient in the desert of Nevada have a bad mold & dust mite allergy?
those living with swamp coolers!
35
What are the rural pollen allergy problems?
grass, ash, hazel, plantain, whatever plants/trees are deciduous
36
What are the urban pollen problems?
not the deciduous trees, but the planted trees. ornamental trees.
37
T/F Lack of redness & itch on allergy testing doesn't necessarily rule out that allergen.
FALSE. No mast cell response--no redness/itch--no allergy.
38
What is the most important part of allergy therapy?
avoidance therapy--get rid of the cat.
39
When should allergy medications begin for allergic rhinitis?
before the season of allergies | b/c once the mast cells are activated, difficult to control.
40
WHat forms do medications for allergic rhinitis come in?
liquid pill nasal spray
41
Easter Memorial Day Labor Day What are the allergens @ each of these seasons?
Easter-tree season Memorial Day--grass season Labor Day--weed season
42
What are some important antihistamines?
``` cetirizine fexofenadine loratidine diphenhydramine hydroxyzine azelastine nasal spray ```
43
What do you need to know about cetirizine?
``` OTC & cheap allergic rhinitis & allergic conjunctivitis once daily rare sedation syrup or tab ```
44
What do you need to know about fexofenadine?
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
What is the pro & con w/ loratidine?
pro: non sedating con: not as effective
46
What is the problem w/ diphenhydramine?
SEDATION | and need to take 6X/day for continuous relief
47
HOw often do you need to take hydroxyzine? Is it sedating?
less sedation than benadryl | 4X/day
48
What is important to know about azelastine nasal spray?
1 puff in nose2X/day tastes terrible!!! could cause a nosebleed
49
When a child has an eye problem w/ allergies...what is the best route of delivery ?
NOSE! Kids hate stuff in their eyes.
50
What is cromolyn?
good for allergic rhinitis OTC pretreatment. nasal spray
51
T/F You can use Montelukast, leukotriene receptor antagonist, to treat AR and asthma.
True. 1X/day
52
What are the steroid options for AR?
intranasal steroids fluticasone Princess nose spray b/c it smells good.
53
What's awesome about allergy immunotherapy?
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
What are the 2 forms of immunotherapy for allergies? What are the pros/cons?
SCIT: greater risk for anaphylaxis SLIT: covers one allergen
55
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58
Eosinophilic & neutrophilic inflammation exists in what age group of asthma? Viral driven?
Children/adults--eosinophils/neutrophils | Young children-viral
59
As your child grows the likelihood of allergy being the cause of asthma increases/decreases?
increases | probably an allergic trigger to the asthma attack.
60
What are the symptoms of asthma?
``` wheezing--expiration>inspiration cough w/ exertion or sleep chest tightness SOB w/ exertion allergens, thunderstorms, cold air, laughing, smoke exposure increases ```
61
Spirometry improvement from baseline of >____% after ___ use for asthma diagnosis.
>10-12% w/ SABA use
62
What are alternative diagnoses to consider w/ children who you think may have asthma?
Consider in alternate diagnosis in children: foreign object, rings, vocal cord dysfunction, CF, BPD, CHF. Particularly if first episode or unilateral.
63
What are alternative diagnoses to consider w/ adults who you suspect to have asthma?
Consider CHF, Foreign object, COPD, Smoking, CVID, alpha-1 antitrypsin deficiency, Lung Cancer in adults/ geriatrics
64
Which age group has the highest prevalence of transient early wheezers? non-atopic wheezers? Ig-E associated wheeze/asthma?
Transient--0-3 Non-atopic: 3-6 IgE: climbs across age groups, more common in older children & adults
65
THe wheezing child <3 yo has increased risk of asthma if they meet which major criterion?
at least 1 parent w/ asthma atopic dermatitis inhalent allergen sensitization
66
THe wheezing child <3 yo has increased risk of asthma if they meet which 2 minor criteria?
``` at least 2 allergic rhinitis wheezing apart from colds eosinophilia food allergen sensitization ```
67
What is the major evidence of obstruction in an asthma patient?
FEF25-75, really see pattern of expiration; see decreased in asthma.
68
What is FeNO measurement used for?
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
Give the major spirit of asthma diagnosis.
airway obstruction reversible w/ bronchodilator | do flow volume loops at least 1-2/year
70
When do you say--this kid is a high risk asthma patient?
``` 2 or more oral steroid bursts/year ER visits Hospitalizations Potentially Fatal Asthma (ICU stay or intubation). Poor PFTs ```
71
What are ways to assess how well controlled the asthma is?
``` cough? wheeze? SOB? frequency of symptoms? attacks/albuterol use? PFTs? ```
72
What makes you run to an asthma patient?
silent chest no inspiratory or expiratory wheezing...things have progressed negatively look for PO2, cyanosis, insp airflow & exp wheezing, accessory muscle use, CNS
73
What meds do you use w/ acute asthma management in ICU?
continuous albuterol nebulization terbutaline IV or subcu heliox--decreases turbulent flow in the airways, more laminar & efficient route to the alveoli
74
What is the rescue management for asthma?
beta agonists, SABA
75
What is the long term medical management of asthma?
inhaled steroids leukotriene receptor antagonists LABA allergen avoidance
76
What might be a good treatment option for mild asthmatics, particularly kids?
episodic inhaled glucocorticosteroid
77
What are good drugs to add on to asthma management?
LABA leukotriene antagonist theophylline-neutrophilic asthma, steroid sparing anticholinergic-tiotropium roflumilast (PDE inhibitor)-neutrophilic asthma, prob not for children.
78
Step management
https://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf
79
How do you assess severity?
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
How do you assess control?
``` symptoms occurrence nighttime awakenings interference w/ normal activities SABA Lung Function, FEV1 oral steroid bursts side effects from meds ```
81
Steps 1-6; management?
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
Big risk for omalizumab?
anaphylaxis.
83
What are indications for consulting an allergist for an asthmatic patient?
over 400 micrograms of inhaled steroid per day | hospitalization
84
What is a moderate dose of corticosteroids?
400 micrograms.
85
What MUST you know about prescribing LABA?
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
T/F Unopposed continuous albuterol is a bad idea.
True.
87
Cromolyn works how?
anti-inflammatory weak 4X/day
88
Is theophylline used in the hospital?
no, b/c takes too long to use IV | need to check levels b/c it can cause hypokalemia, arrhythmias, seizures
89
When should ipratropium be used?
ipratropium is useful in ER to prevent ICU stays | not effective in nebulizer at home
90
Can you use epinephrine to treat a severe asthma attack?
yes. but it only seems to be effective for up to 3 doses.

BLOCK 9; Week 4-M (8 decks)

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