Flashcards in Atopic Disease Deck (131):
atopic diseases focuses on ___ which includes _____
-eczema or atopic dermatitis,
other words for allergen
if a patient has an allergy, when do they develop that hypersensitive response? Why?
upon their second exposure-- sensitization needs to have occurred prior to the allergic reaction and in order to be considered an allergic reaction it must be reproducible on future exposures to that same allergen
describe how an allergic/hypersensitive Type I reaction occurs
1st exposure to antigen--> IgE made--> IgE attaches to mast cells--> 2nd exposure, antigen attaches to IgE on mast cell activating it--> causes degranulation --> release of histamine and leukotrienes
Children with atopic disease often have early evidence of their hypersensitivity during early childhood, usually in the form of _____ and then ___
describe the "atopic march" of atopic disease development
1. evidence of their hypersensitivity during early childhood in the form of ECZEMA (1-2y/o))
2. FOOD ALLERGY, if it occurs, usually presents around the same time or just slightly later (1-2y/o)
3. ASTHMA presentation usually before age 5 (peaks at 5y/o)
4. then in their school years, the development of seasonal NASAL ALLERGY symptoms (10y/o)
what atopic diseases typically improve with age and what ones persist?
-many children outgrown their hypersensitivity to food allergens, and usually their eczema improves as they age
-In atopic patients, the allergic rhinitis and asthma components of their disease will usually persist
risk factors for atopy
1. a biological parent or sibling with any of the atopic diseases
2. personal history of eczema or food allergy
3. family hx of food allergy
what are the most common food allergens in children
1. peanuts (a legume)
2. tree nuts
5. cow's milk
patients with peanut (a legume) allergy have a ___% risk of also being allergic to tree nuts (almonds, walnuts, pecans, etc.) and children with cow’s milk allergy are more than ___% likely to have soy allergy too
there is protein antigen similarity between what food items? and what is the reaction
-bananas, melons, kiwi and ragweed
-pollen, carrots, and celery
*While patients with hypersensitivity to these last 2 groups generally have oral allergy symptoms only, they can have anaphylaxis and it is recommended that they avoid these foods in their diet.
The diagnosis of anaphylaxis requires any 2 of the following:
1. Any cutaneous symptom
2. respiratory compromise (wheezing, respiratory distress, hypoxia, stridor)
3. symptoms of reduced blood pressure. (syncope, hypotonia)
4. GI symptoms .
*These symptoms MUST occur within minutes to several hours after exposure to a likely allergen/food ingestion .
skin reactions to food allergies
4. angioedema (swelling)
ocular/upper respiratory reactions to food allergies
3. red eyes,
4. periorbital edema,
lower resp. reactions to food allergies
4. respiratory distress
oral reactions to food allergies
1. lip or tongue swelling
2. oral itching
GI reactions to food allergies
3. colicky abdominal pain
cardiovacular reactions to food allergies
2. hypotension w/ sx of dizziness and fainting
non Ig-E mediated food reactions
1. Food aversion
2. Food intolerances (ex. lactose intolerance)
3. Toxic food reactions
4. Hypersensitivity Reactions involving T-cells, eosinophils and IgG
-Eosinophilic esophagitis (EoE)
-Food-protein induced enterocolitis and proctocolitis
how do food aversions present
will gag and vomit foods due to taste, texture, temperature, etc.
sx of lactose intolerance (food intolerance)
-possibly diarrhea and
-be reproducible with milk product ingestion
how do toxic food reactions present
are reactions such as food poisoning, ingestion of certain fish toxins, etc. and because they are not reproducible are usually a bit easier to sort ou
what is the presentation of EoE (eosinophilic esophagitis), enterocolitis/proctocolitis, and celiac disease?
(hypersensitivity rxns involving T-cells, eosinophils, and IgG
EoE patients present with vomiting, reflux and swallowing difficulties, whereas the enterocolitis/proctolitis group present with bloody stools and diarrhea, and the celiac disease group with diarrhea, greasy stools, poor weight gain.
*separate from IgE mediated diseases by lab testing
what is work up of assessing a pt with a hx of urticaria, suspected anaphylaxis or suspected IgE GI sx
1. ask about risk factors
2. onset of sx?
3. type of sx (hives only, GI sx alone, anaphylaxis?)
4. history of sensitization
5. suspected allergen
6. exam (rarely helpful in primary care)
if a patient has a FH of asthma, with a personal history of profuse vomiting and diarrhea after eating fishsticks on two previous occasions and now presents with urticaria and periorbital angioedema, you have convincing history for ___
Ig-E mediated fish allergy
*There is no way to predict whether this child may have a anaphylactic reaction to fish in the future, so it is important to stress the importance of dietary avoidance of fish
why do some pts have an allergy to a raw food and not the same food cooked?
Cooking denatures the protein allergen in some foods like fruits and vegetables, but not so in meats and grains.
-Therefore, you may have a history that the child can tolerate cooked carrots, but will develop hives and lip swelling if they eat them raw.
-This information is helpful in diagnosing the patient with an Ig-E mediated food allergy to carrots.
when is laboratory testing not necessary with food allergies
-oral allergy syndrome
what is the gold standard to "prove" food allergy and when is it used
- an oral food challenge.
*Because it is not possible to predict whether a patient may have anaphylaxis if they ingest something they are suspected of being allergic to, this is not a practical approach.
-It is used in patients who are thought to be developing tolerance (outgrowing) their food allergy, but only in the setting of an allergist office with the ability to deal with an anaphylactic reaction.
types of lab testing of IgE mediated hypersensitivity to food
1. Specific Ig-E testing (ImmunoCap)*
2. Skin prick test (SPT)*
3. Oral food challenge--Gold standard, not necessarily safe
4. IgE RAST testing-- not that helpful
why is the IgE RAST testing not that helpful
IgE RAST testing in multiple item panels is not helpful as these tests look for in-vitro reactions to multiple allergens together and have a high false-positive rate.
when would you use an Immunocap and SPT?
-ImmunoCap is often used in small children as skin prick testing is difficult to tolerate. With ImmunoCap testing you are testing for serum IgE response to a specific allergen, so your history is important for knowing what to test for.
-ImmunoCap testing is non-invasive and can be performed in a primary care office.
-Skin prick testing is more broad-based with multiple likely allergens chosen and in-vivo wheal response detects the presence of sensitization.
-SPT should be done in an allergist office due to the risk of anaphylaxis during the testing process.
can you diagnose a food allergy w/ SPT or immunoCap a lone
*Alone, neither SPT or ImmunoCap is diagnostic of food allergy, as a patient may be sensitized to a food, but not have an allergic reaction if they ingest that food, so the key components are + lab testing and a history suggestive of a reaction to that food.
if ImmunoCap and/or SPT are negative, but the history is strongly suggestive, the allergist may perform ____.
*It is generally recommended that if a patient’s history is suggestive of an IgE mediated food hypersensitivity to refer them to an allergist for further evaluation and management.
an oral food challenge
management strategies of food allergies
1. **dietary avoidance (foodallergy.org)-- elimination diets
2. EpiPen- Epi-Pen and Epi-Pen Jr (<25kg patients)
*risk of death from anaphylaxis
what are elimination dies
-involves dietary removal for a few weeks of any of the 6 most common allergens(not including shellfish, peanuts, tree nuts) when a +ImmunoCap response has revealed a sensitization but clinical food allergy has not been determined.
*An elimination diet is best used in infants
Data suggests that the patients most at risk for anaphylaxis death are:
adolescents/young adults with poorly controlled asthma and peanut allergy. Patients who have died from peanut anaphylaxis have been aware of their peanut allergy and the importance of an EpiPen but either did not have it with them or failed to use it in a timely manner.
do children w/ peanut allergies need to avoid contact w/ peanuts?
-they do NOT need to avoid any and all contact with peanuts.
-Peanut “dust” in the air, products that contain peanuts touching their intact skin, etc. are NOT associated with peanut anaphylaxis or allergic reaction
* It is prudent, however, for child care sites that care for young children, some of whom are known to have peanut allergy, to avoid peanuts or peanut-containing products in their facility due to children’s tendency to share food.
Patients are likely to develop tolerance to milk, soy, wheat, egg by the age of ____ and oral food challenges are sometimes attempted in these children.
____ are less likely to be outgrown
*Nut and shellfish allergies are much less likely to be outgrown
ways to prevent food allergies
1. Eliminating foods from the diet of a lactating mother or stopping breastfeeding is discouraged
2. Avoiding the 8 common allergenic foods in at-risk children is currently not recommended.
3. important to delay ingestion of solid foods in all children prior to age 4 months, as their gut is more permeable and feeding solid foods early is associated with increased IgE-mediated hypersensitivity later
At this time, the only routine vaccination that is NOT recommended in patients with a history of egg anaphylaxis/urticaria is ___.
*An allergist may be able to administer influenza vaccine to the patient using extra precautions.
Infants with moderate to severe atopic dermatitis which responds sub-optimally to appropriate topical therapy with moisturizers and steroids, should be considered a candidate for Ig-E mediated hypersensitivity to one or more of which foods:
1. cow's milk
*If they are breastfed, they are ingesting the proteins of these foods through breastmilk. If they are formula-fed, they are either on cow’s milk formula or soy formula (which can be cross-reactive), and are being exposed to those proteins.
when is ImmunoCap testing done on infants?
-after age 6 months, when circulating maternal antibodies are reduced
-it is important to control as much skin inflammation as possible prior to the ImmunoCap test because excessive circulating IgE from severe atopic skin inflammation can cause false positives
what should you do if you suspect a food allergy is resulting in a severe infant atopic dermatitis
-Switching these infants from cow’s milk or soy formula to an elemental, hypoallergenic formula such as Alimentum or Nutramigen is sometimes remarkably helpful in clearing their atopic dermatitis, and may prevent further food allergy.
-Because the benefits of exclusive breastfeeding through the age of 4-6 months outweigh the benefits of atopic control, it is not recommended to switch exclusively breastfed infants to a hypoallergenic formula.
These hypoallergenic formulas contain only ____, so they do not trigger hypersensitivity response.
*They are about double the cost of regular formula, and they are covered on the Women, Infant and Children (WIC) nutritional program with a provider’s authorization form.
risk factors for persistent asthma
major criteria: parent w/ asthma or hx of atopic dermatitis
-maternal hx of atopic diseases or allergic rhinitis
-over 4% eosinohpilia
-hx of wheezing not associated with URI
*Having even 1 major criteria greatly increases the chance the child does or will have asthma. Having 2 minor criteria also increases the likelihood.
describe what asthma is
-a disorder characterized by airway hypersensitivity, usually with a significant Ig-E mediated component, which results in inflammation including mucus secretion and edema, and smooth muscle airway constriction
-not all sx are Ig-E mediated and other types of hypersensitivity have been identified
-Over time, the smooth muscle layer of the airways can become hypertrophied with collagen deposition in the basement layer leading to permanent lung remodeling.
number 1 environmental risk factors for asthma
tobacco smoke exposure
A history of RSV bronchiolitis in infancy has been implicated in the later development of __
mitigating household allergens
*In more humid climates than super-dry Colorado, dust mites are often the culprit.
history clues to asthma
1. Major and minor criteria
2. Nocturnal cough during well periods
3. Exercise intolerance
4. Hx of RSV bronchiolitis, wheezing with URI’s
5. Previous use/response to albuterol
6. dry cough between 2-4am
7. wheeze during well periods
8. visible increased work of breathing
why do pts with asthma cough a lot at night
It is the natural circadian rhythm to decrease epinephrine levels during these early morning hours and epinephrine is a potent bronchodilator.
-When it decreases, these patients experience bronchoconstriction and begin to cough
what group of children are mostly likely to "outgrow" their asthma around age 6 and why?
-cough w/ play
-wheezing with URIs
- “outgrow” their asthma around age 6 as their airways become anatomically bigger
ddx for wheezing
2. Foreign Body Aspiration
3. Congestive Heart Failure
4. Anatomical Malformations
6. Cystic Fibrosis
*esp. in age 0-y/o
gold standard for asthma testing as well as following asthma progression or improvement with treatment
spirometry (so testing the ability to force air volume from the lungs )
-Not useful in children less than 4-5 y/o (have to follow complex instructions)
-May be combined with a methylcholine challenge (test hypersensitivity) and/or albuterol treatment (shows reversibility of their bronchoconstristion)
classes of asthma
how do you classify asthma
Use of albuterol or rescue inhaler less than/equal than 2 x/week = mild persistent asthma
Nocturnal cough/wheezing greater than 2x/month = moderate persistent asthma
Symptoms all the time= severe persistent asthma
*Pre-exercise treatment with albuterol does not count in these numbers, but a need for albuterol during/after that pre-treatment does
Once they are on asthma treatment, similar benchmarks are used to determine of the patient’s asthma is well-controlled, not well-controlled, or very poorly controlled:
Generally those benchmarks look similar to these “Rules of 2” in 5-11 year olds, but has a small change for those 0-4 years old in that nocturnal cough should not occur >1x/month.
how do you assess asthma at each visit
1. asthma control test (ACT)
-allows patient/parent to indicate the level of sx
-helps us to determine the patient’s level of asthma control
2. check med adherence
3. review envirnomental exposure/control
4. device techniques
5. tx co-morbid diseases: rhinitis and sinusitis, obesity, gastroesophageal
reflux, obstructive sleep apnea, stress, depression or anxiety, allergic bronchopulmonary aspergillosis.
Patients classified as intermittent asthmatics will remain on ____, while persistent asthmatics will need to have ____
short-acting bronchodilators (SABA)
additional medications starting with an inhaled corticosteroid (ICS).
A mild persistent asthmatic will use Step __ treatment, a moderate persistent will use Step __ depending on their severity, and severe persistent will use Step __.
mild- step 2
moderate- step 3 or 4
severe- step 5 or 6
when should an asthmatic be referred to a pulmonologist for eval. and managment?
Severe persistent asthmatics or any child requiring step 4 or higher therapy
The preferred step up between low dose ICS and medium dose ICS is to add ___
a long-acting beta agonist (bronchodilator) LABA prior to moving to medium dose ICS.
The go-to ICS for children less than 4 for most providers is ___ , and once a moderate-persistent child reaches age 4y, the ____ is a great choice
Advair diskus with fluticasone and LABA-
*While its use is off-label, we do use fluticasone alone (Flovent) in children less than 4y/o but keep it to low dose
what approaches do some providers take to try to control ones asthma sx
that some providers provide therapy in children who have recently been discovered to be using their SABA excessively and have no recent history of ICS use to get them under control and then step them down.
-Other providers will start them on an ICS and see them back in a couple of weeks to look for improvement vs. need to step them up to a higher level
Children old enough (___) to be taught how to use peak flow should receive instruction on recognizing their green, yellow and red zones on these expiration measuring devices.
how do you determine a child's green, yellow and red asthma zones?
3 measurements are taken when well, and then the best of the 3 is used as their peak expiratory number. Asthma action plans then use 70% of best as yellow zone, and 50% of best as red zone.
why is the asthma action plan important for children w/ asthma
The asthma action plan reminds them of the controller medications (LABA,ICS, LTRA) that they need everyday, and instructs them on the use of their rescue inhaler (SABA) when their peak flow values drop into the yellow or red zone. These also include instructions on when to come into the clinic or ED.
Children should always be given ___ with MDI’s due to their propensity to spray the medication into their mouths rather than inhaling into their lungs.
Educate parents on the importance of their controller medications in preventing ___
exacerbations as well as lung remodeling
asthma education includes
1. peak flow meters
2. valve or valve-mask spacers
3. asthma action plan
4. allergen control
5. tobacco smoke
goals of asthma management
1. No exercise limitations
2. No missed days of school due to asthma
3. No ER or unscheduled clinic visits due to asthma
4. No nocturnal cough
5. less than 2x/week SABA use
allergy testing in these kids- it used to be done routinely followed by allergy shots (desensitization therapy), but that isn’t often done anymore becaus __
as the newer medications are so effective at controlling symptoms and most kid’s environmental allergies can’t be avoided.
workup of wheezing in children less than 4y/o
1. Hx of current illness (freq. of wheezing, response to albuterol, triggers for wheezing-viral, exercise, exposure)-allergies, eczema
2. Fhx of asthma
3. environmental exposures
4. PE (FTT, clubbing, persistent hypoxia?)
5. response to albuterol??
6. (Y) Episodic wheezing?-- frequent episodes of wheezing w/ RTI only (transient wheeze are more likely to stop wheezing by age 6)
7. (Y) Multiple trigger wheezes/persistent asthma- wheezing w/ RTI and between illness due to other triggers AND/OR not meeting monitoring goals for min. 2-4 weeks
*look for wheezing w/ URI or LRI w/o major or minor criteria
tx of wheezing in children less than 4y/o
-use SABA with a spacer to reduce bronchoconstriction
-Oral corticosteroids (prednisone or prednisolone at 1-2mg/kg/d given QAM x 5d) are often used as an anti-inflammatory agent to reduce airway edema and mucus plugging
tx of children w/ repeated eipsodes of wheezing associated w/ URI/LRI
-possible to use high-dose ICS for a week at the first sign of illness to reduce inflammation and decrease the possibility of increased respiratory distress requiring ED or inpatient management.
management of acute asthma exacerbations
-2-4 puffs SABA via MDI/Spacer
-Repeat x 3 q 20 minutes
-Oral corticosteroids (x5 days)
*f/u 1-3 days to assess improvement
In clinic, we can __, __, and __ by providing SABA treatment. The preferred way to do this is:
decrease their wheezing, improve their air movement and oxygenation
*While this can be done via nebulizer, it is preferable and equally effective to use an MDI (with spacer if young child) and you can increase to 4 puffs. Repeat up to 3 x.
when might a patient need inpatient care or evaluated by ED for an asthma exacerbation
If patients have significant respiratory distress, need for supplemental oxygen, or have rebound wheezing, SOB after SABA or don’t respond well to SABA
*possibly need to be observed w/ continued use of SABA
Approximately __-__% of children are affected with food allergy. In adults this declines to __%
6% to 8%
Onset: minutes to 2 h
Nausea, abdominal pain, emesis, diarrhea
Typically in conjunction with cutaneous and/or respiratory symptoms
acute GI hypersensitivity (IgE mediated)
History, positive PST, and/or serum food-IgE
acute GI hypersensitivity (IgE mediated)
History, positive PST with raw fruits or vegetables; OFC-positive with raw fruit, negative with cooked
Pollen-food allergy syndrome (oral allergy syndrome)
characteristics: children: chronic/intermittent symptoms of gastroesophageal reflux, emesis, dysphagia, abdominal pain, irritability Adults: abdominal pain, dysphagia, food impaction
History, positive PST, and/or food-IgE in 50%, but poor correlation with clinical symptoms
Patch testing may be of value Elimination diet and OFC
Endoscopy, biopsy provides conclusive diagnosis and response to treatment information
Allergic eosinophilic esophagitis
(IgE or non-IgE mediated)
characteristics: Chronic/intermittent abdominal pain, emesis, irritability, poor appetite, failure to thrive, weight loss, anemia, protein-losing gastroenteropathy
History, positive PST, and/or food-IgE in 50%, but poor correlation with clinical symptoms, elimination diet, and OFC
Endoscopy, biopsy provides conclusive diagnosis and response to treatment information
Allergic eosinophilic gastroenteritis
(IgE or non-IgE mediated)
characteristics: blood-streaked or heme-positive stools, otherwise healthy-appearing
diagnosis: History, prompt response (resolution of gross blood in 48 h) to allergen elimination
Biopsy conclusive but not necessary in vast maj
Allergic proctocolitis (non-IgE mediated)
characteristics: Chronic emesis, diarrhea, failure to thrive on chronic exposure
On reexposure following a period of elimination, subacute, repetitive emesis, dehydration (15% shock), diarrhea
dx: History, response to dietary restriction
Food protein-induced enterocolitis syndrome
(non- IgE mediated)
characteristics: Protracted diarrhea, (steatorrhea), emesis, failure to thrive, anemia in 40%
Dx: History, endoscopy, and biopsy
Response to dietary restriction
Dietary protein-induced enteropathy
characteristics: Chronic diarrhea, malabsorption, abdominal distention, flatulence, failure to thrive or weight loss
May be associated with oral ulcers and/or dermatitis herpetiformis
dx: Biopsy diagnostic: villus atrophy
Screening with serum IgA antitissue transglutaminase and antigliadin
Resolution of symptoms with gluten elimination and relapse on oral
Celiac disease (gluten-sensitive enteropathy)
__ can be performed to confirm IgE-mediated food allergies
Skin prick testing
*A negative skin test virtually excludes an IgE-mediated reaction (unless the clinical history suggests a severe reaction after an isolated ingestion of the food).
*A positive skin test indicates sensitization but does not prove clinical reactivity and must be interpreted, based on the history
method uses a quantitative fluorescent immunoassay, which is more sensitive than other assays; this method also has improved specificity and reproducibility compared to other assays.
Hypersensitivity to __, __, __, and ___ resolves within the first 5 years of life in approximately 80% of children
egg, milk, wheat, and soy
Sensitivity to certain foods, such as __, __, __, and ___, tends to be lifelong.
peanuts, tree nuts, fish, and shellfish
*However 20% of children who manifested peanut allergy younger than 2 years of age may outgrow it.
Recommendations for prevention of allergic diseases aimed at the high-risk newborn who has not manifested atopic disease include:
1. Breastfeed for first 4-6 months OR
2. use hydrolyzed casein formula OR
3. partially hydrolyzed whey formula
4. delay introduction of solid foods until 4-6 months of age
The most common physical urticaria is ___, affecting __-_% of persons
dermatographism, affecting 2% to 5% of persons
characterized by the appearance of 1- to 3-mm wheals surrounded by large erythematous flares after an increase in core body temperature, occurs commonly in young adults. Lesions may develop during strenuous exercise, after a hot bath, or emotional stress. The lack of airway symptoms differentiates it from exercise-induced anaphylaxis.
how does cross-linking result in anaphylaxis?
Cross-linking of the IgE molecule with the allergen leads to IgE receptor activation on the mast cell and basophil and release of mediators, including histamine, tryptase, tumor necrosis factor, platelet-activating factor, leukotrienes, prostaglandins, and cytokines
-Raised, erythematous lesions with pale centers that are intensely pruritic
- lesions vary in size and can occur anywhere on the body.
-Typically urticaria arises suddenly and may resolve within 1 to 2 hours or may persist for 24 hours.
urticaria aka hives
ddx of urticaria/hives
1. erythema multiforme
2. Muckle-wells syndrome
3. urticarial vasculitis
target-shaped, erythematous, macular or papular lesions that may look similar to urticaria, but the lesions are fixed and last for several days
episodic urticaria presenting in infancy, with sensorineural deafness, amyloidosis, arthralgias, and skeletal abnormalities
small vessel vasculitis with histologic features of a leukocytoclastic response. The main distinguishing feature is that the lesions last longer than 24 hours, may be tender, and leave behind skin pigmentation.
tx for acute anaphylaxis
3. IV fluids
4. supine position
5. call 911!
what do hives look like?
raised, red, blurred edges bc they sometimes tough eachother, irregular borders/shaped, +/- warmth, very itchy!! (histamine rxn), coming and going*
if kid is reactive to a lot of things and w/ a fuzzy hx--- try
can people have IgE mediated responses w/ soaps/detergents
New foods and soaps and detergents--> contact dermatitis- does not need to be prior exposure w/ soap/detergents (non-IgE mediated)
***w/ foods- need to have eaten prior to get sensitized (IgE mediated process
1. cig. smoke
3. dust mites
6. pets, animals
7. pollen, plants
8. strong odor
9. weather change
green zone for AAP
Have all of these:
no cough or wheeze
sleep through the night
can work and play
yellow zone for AAP
you have any of these:
-first signs of a cold
-exposure to a trigger
-coughing, wheezing, or trouble breathing at night
*use albuterol 2 puffs, every 20 min. for up to 1 hour if needed, and then every 4 hrs as needed
red zone for AAP
Your Asthma is getting worse fast:
-med is not helping
-breathing is hard and fast
-nose opens wide
-can't talk well
*use albuterol 4 puffs once, repeat in 20 min if needed
asthma danger signs:
-lips or fingernails are blue
-person is confused
-difficulty walking and talking due to SOB
what is normal spirometry?
FCV: over 80% predicted
FEV1: over 80% predicted
FEV1/FVC (FEV1%): norms based on age +/-5% (of predicted)
FEV1/FVC (FEV1%) Normals for:
5-19 y/o-- greater or equal to 85%
20-39 y/o-- greater or equal to 80%
40-59 y/o-- greater or equal to 75%
60-80 y/o-- greater or equal to 70%
what does asthma look like on spirometry?
Meets the following criteria:
1. Shape of the curve is concave.
2. FEV1/FVC (FEV1%) is decreased
3. FVC (largest)-- FEV1 -- FEF25-75 (smallest)
4. A 12% and at least 200ml increase in FEV1 post
*Boot or "L" shaped
severity rating for asthma based on spirometry
Mild: 0.00 - 0.04* or over 80%
Moderate: 0.05* or 60 - 80%
Severe: less than 0.05* or less than 60%
1 minute interpretation of spirometry: 5 things to check:
1. Is the entry data correct?
-Check age, height, weight, sex and race
2. Evaluate the quality of the blow
-Good effort with rapid rise to peak flow? Is the curve smooth and reproducible?
3. What is the shape?
-Normal, obstructive, restrictive or mixed? Is the inspiratory loop cut off?
4. Look at the percentages for the shape chosen
-Mild, moderate, severe
5. State your interpretation
-e.g. “mild airway obstruction”
what does restrictive disease look like on spirometry?
- Pulmonary Fibrosis/ILD
what does fixed large airway obstruction look like on spirometry?
- Glottic or tracheal stenosis
- Tracheal malacia
- Paratracheal/Intratracheal mass - Vocal cord paralysis
- Foreign body
what does variable extrathoracic airway obstruction look like on spirometry?
- Paradoxical vocal cord dysfunction
what does variable intrathoracic airway obstruction look like on spirometry?
- Movable mass lesion
if a patient does not respond to albuterol tx for wheezing what other diagnoses should be considered
-airway malacia or compression
describe the tx of wheezing for those 0-4 y/o
Step 1: Preferred: SABA
-as need for sx q 4-6 hrs
Step 2: Preferred: Low dose ICS
-Alternative: Cromolyn or montelukast
Step 3: Preferred: Medium dose ICS
Step 4: Preferred: Medium dose ICS + either LABA or montelukast
Step 5: Preferred: High dose ICS + either LABA or montelukast
Step 6: Preferred: high dose ICS + either LABA or montelukast + oral systemic corticosteroid
**consult asthma specialist if step 3 care or higher is required. consider consultation at step 2
when following the 6 Steps of asthma management, what do you need to do before increasing to the next step?
first, check adherence, inhaler technique, and environmental control
when following the 6 Steps of asthma management, what do you want to consider before decreasing to the previous step?
is asthma well controlled at least 3 months
re-evaluate any child 0-4y/o started on a daily asthma medication in _____
For asthma, re-evaluate every ____ for daytime symptoms, exercise limitation, albuterol use and wheezing episodes.
how do you treat intermittent asthma in children over 5
-if use more than 2 days per week (other than for exercise) consider inadequate control and the need to step up treatement
how do you treat persistent asthma in children 5 y/o
Step 1: SABA
Step 2: Preferred: low dose inhaled steroid
-alternative: leukotriene blocker or cromoyln
Step 3: Preferred: low dose inhaled steroid + LABA
-alternative: medium-dose inhaled steroid OR low dose inhaled steroid + leukotriene blocker
Step 4: Preferred: medium dose inhaled steroid + LABA
-Alternative: medium dose inhaled steroid + leukotriene blocker
Step 5: Preferred 5-11y/o: high dose inhaled steroid + LABA
-alernative: high dose inhaled steroid + leukotriene blocker
12+: high dose inhaled steroid + LABA AND consider omalizumab if alleries
Step 6: 5-11y/o Preferred: high dose inhaled steroid + LABA + ORAL steroid
12+: high dose inhaled steroid + LABA and consider omalizumab if allergies
what are the criteria for well controlled asthma?
1. Daytime sx: Less/eq. 2days/week
2. Nighttime sx: less/eq 2x/month
3. Limitation of activities: none
4. SABA use for sx control: less/eq 2days/week
5. ACT: score greater/eq 20
6. Course of prednisone in last year: less than 2
7. Spirometry: FEV1%= over 80% of predicted or personal best, FEV1/FVC= normal ratio for age
*nl ratio 5-19y/o = 85% and over
what are the criteria for NOT well controlled asthma?
1. Daytime sx: over 2 days/week
2. Nighttime sx: 1-3x/week
3. Limitation of activities: some limits
4. SABA use for sx control: over 2days/week
5. ACT: score 16-19
6. Course of prednisone in last year: greater/equal 2
Spirometry: FEV1%= 60-80% of predicted, FEV1/FVC= 5% 7. or less decrease in ratio for age
nl ratio 5-19y/o = 85% and over
what are the criteria for very poorly controlled asthma?
1. Daytime sx: throughout the day
2. Nighttime sx: greater/eq. 4 x/nigh
3. Limitation of activities: extremely limited
4. SABA use for sx control: several times/day
5. ACT: less/equal 15
6. Course of prednisone in last year: greater/eq. 2
7. Spirometry: FEV1%= less than 60% of predicted, FEV1/FVC= over 5% decrease in ratio for age
*nl ratio 5-19y/o = 85% and over