Standard Protocol for "Asthma Action Plans"

[LinksEtc]

There seems to be a gap between some "Food Allergy Action Plans" and "Asthma Action Plans" because the FA plan is only referred to if there is a "suspected or known ingestion" whereas anaphylaxis may occur even if allergy is not initially suspected.

By having the experts make a few standard changes or recommendations to "Asthma Action Plans", I'm wondering if the judgment calls currently needing to be made by parents, schools, etc. can be reduced.  Plus, it would assure schools that the patient's different doctors are in agreement with how to proceed with treatment of isolated respiratory symptoms in a patient with both asthma and severe food allergy.

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Feel free to comment to explain your answers.  Thanks!

[rebekahc]

Usually but with exceptions

I think most asthma kids don't get into their red zone very often and if they do it should be considered an emergency, so yes, epi should be considered if they end up in the red zone at school.  DS however, has been known to spend days/weeks fighting to get out of the red zone.  There's just no way we could have given him epi all the time like that.

[Janelle205]

I'd say with the majority of those with asthma, probably.

But like rebekah's ds, if my plan was to epi in the red zone, I'd be doing it all. the. time.  My asthma plan does include epi as a last resort though.

[LinksEtc]

Thanks for sharing your opinions, I really appreciate it.  Very good points made.

[PurpleCat]

That has never been our plan for red zone asthma attacks.  If a rescue inhaler at it's prescribed interval is not enough - we have been instructed to use it more frequently while in phone contact with the doctor on call and then if results are still not improving, it's the ER.  They have never had us use an Epi.

At the hospital they have never used an Epi.  Steroids and child bouncing off the wall and observation for hours until it is safe to go home.

DD has not been that bad in years - we are lucky her asthma is fairly well controlled now.

I have a memory of one of those nights when she was high as a kite on steroids and the cutest little 3 or 4  year old.  She's sitting up on the top of the ER desk, licking a red popsicle, and chatting with 3 doctors like she was holding court.  I was exhausted sitting across the way in her room unable to move!  She had them engaged for quite a while.

[mkobhu2]

in my view using a epi for this purpose should only be done as a last resort, or as a survival method, I personaly have never heard of epi's being used to combat asthma, and just as a reminder epi's are dangerous and when added in to some situations can cause the heart to over beat

[LinksEtc]

I'd like to give a little background on why I started this poll:

1.  From the article "When Anaphylaxis Looks Like Asthma" page 11 - 13 of this link
http://www.aanma.org/pdf/AnaphylaxisGuide.pdf

Inhalers won't stop anaphylaxis, but epinephrine will
stop either an asthma attack or anaphylaxis. So if in doubt,
use epinephrine and cover your bases.

2.  Another mention of possibly using Epi is found here:
"Sudden Death: British High School Student's Case Raises Questions"
http://www.asthmaallergieschildren.com/2012/01/11/sudden-death-british-high-school-student%E2%80%99s-case-raises-questions/

whether this was a case of food allergy anaphylaxis or asthma or both epinephrine is the best emergency treatment for both kinds of airway constriction, but the double duty makes prompt use even more critical.

*********************************

I wish asthma & FA doctors could come up with more guidance on the issue, although it appears there would not be a one-size-fits all plan to deal with severe respiratory symptoms in somebody with both asthma & FA.

ETA - of course, if FA is suspected, the FA Action Plan should be referred to right away and that would call for epi.
What I'm talking about is when FA is not initially suspected, so the asthma action plan is being followed.

[Janelle205]

I don't think that I would consider epi to be dangerous, except for in a small subset of the population with other issues.

When I was initially prescribed epi, the allergist told me that he was prescribing it not only because of my reactions, but also because of the severity of my asthma attacks. 

Several doctors and a respiratory therapist have all told me that the pen will work for a severe asthma attack.  And I have a heart condition - they consider the risk from a severe asthma attack to be higher than the danger to my heart, which isn't going to do much good if I stop breathing anyway.

Of course this is a last resort.  But I have commonly worked places where an ambulance is at least 10-15 minutes away, and the nearest hospital is around an hour.  But I was very close to using the epi for an attack about a month ago, and I live in the city now.  I had already done two vials of albuterol and one of atrovent.  If the 3rd vial of albuterol didn't cut it, it was going to be epi and the ambulance, as I was starting to see spots. (Note to anyone who reads this - my pulmo has given me permission to use that much rescue med. Do NOT do that unless your doc is ok with it.)

[LinksEtc]

I wanted to add a few things here ...

"Fatal asthma or anaphylaxis?"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1725974/

Two cases of fatal anaphylaxis are reported who were initially diagnosed as
acute severe asthma, and responded poorly to bronchodilator treatment.
Survivors of "acute asphyxic asthma" should be screened for reactions to
common allergens that provoke anaphylactic reactions. Even if no provoking factor
is identified, the asthma management plan of children who survive an episode of acute
asphyxic asthma should include intramuscular adrenaline (epinephrine) in addition
to conventional bronchodilators.

"WHAT PRIMARY CARE GIVERS NEED TO KNOW ABOUT THE NEW GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN THE US". 2012
http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20Resources/Food-Allergy-Guidelines-Summary.pdf

Severity of future allergic reactions is not accurately predicted by past history.

If patient has FA & asthma & has been prescribed epi .... since FA rxns can be unpredictable, even if no FA resp issues in the past, there still may be some risk.

------------------------------------------------------------------------------

"Ontario Student Dies. First Aid Recommendations For Asthma"
http://blog.onespotallergy.com/2012/10/ontario-student-dies-first-aid-recommendations-for-asthma/

I wonder if Ryan had an allergic reaction to his morning snack, and this was mistaken for an asthma attack and only treated with asthma medication.

"Risk factors for childhood asthma deaths from the UK Eastern Region Confidential Enquiry 2001-2006"
http://www.thepcrj.org/journ/view_article.php?article_id=873

In one case there was documented exposure to nuts prior to death (the patient was known to be nut allergic). Acute severe asthma due to anaphylaxis as a cause of sudden death may be underestimated

"Improving Diagnostic Accuracy of Anaphylaxis in the Acute Care Setting"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027438/

In a study that reviewed the death records of individuals considered to have had an apparent fatal asthma attack, autopsy findings revealed that several of these patients had actually died from anaphylaxis.

[LinksEtc]

"MANAGEMENT OF ASTHMA EXACERBATIONS: School Treatment"
http://www.nhlbi.nih.gov/health/prof/lung/asthma/sch-emer-actplan.pdf
AUGUST 2011

** Consider administering epinephrine if the student is unable to use SABA because respiratory distress or agitation prevents adequate inhalation from the SABA inhaler device and nebulized albuterol is not available and the exacerbation is life-threatening. Administer epinephrine auto-injector in lateral thigh as per local or state epinephrine protocol. Epinephrine is NOT first line treatment for asthma. Albuterol is the treatment of choice. Administration of epinephrine should be rare and is intended to prevent a death at school from a severe asthma attack. Most school nurses will never need to administer epinephrine.

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I am running my concerns/ideas about this general topic by my allergist.  I have a lot of confidence in her opinion - so I'm hoping this nagging idea will either get acted upon or I can feel comfortable letting it go.

[TwoDDs]

I'm with you Links.  The concern you are having and the judgment calls you are worried about folks having to make is - is this a severe asthma attack that will eventually respond to dialation or is this really a food allergy reaction that requires epi RIGHT NOW.

That call makes me uncomfortable sometimes and I know its got to be a killer call for our school nurse.  She's asked us to take her home on days when her asthma was not responding easily and kept saying "I can't be sure what's going on here - it doesn't seem usual for her." - And, that was an attack I had already been treating for 24 hours - so I was SURE it was asthma.  I'd probably be fine with an asthma plan that called for epi at some interval for non-responsivness to dialator - but wouldn't that likely be on the late end of needing epi if what we really had was a progressing food allergy reaction?

Hope I'm making sense.

[LinksEtc]

I'd probably be fine with an asthma plan that called for epi at some interval for non-responsivness to dialator - but wouldn't that likely be on the late end of needing epi if what we really had was a progressing food allergy reaction?

Hope I'm making sense.

Perfect sense!

In the rough sample asthma plan draft (for those with FA) I sent to allergist,

I put a decision in there at the first sign of resp symptoms after green zone box with some evaluations that if true, would send patient away from asthma plan to the FA plan & instruction for epi.

[CMdeux]

I'm interested in this as well-- because we've now seen a couple of reactions that presented this way... at least we THINK that they were reactions, in retrospect.

Why?  Because they didn't linger the way DD's asthma seems to during a flare.

That is, BOOM-- asthma in the low-yellow-to-red-zone-- treat with large influx of SABD (albuterol)-- not helping, not helping, add antihistamines and MORE albuterol, and magically, improvement over 20-40 minutes that leads to no recurrence of the asthma flare when the bronchodilator wears off.

But it's only clear IN RETROSPECT, which is what is so damned scary about these.

Even DD thinks of them as "just asthma" when they present, and with her sensitivity, there isn't always a known food exposure to consider a potential trigger.



We too are going to have to discuss this with our allergist soon.  Just where that bifurcation is, I mean-- when do you begin to think "this is not asthma.... Hmmm... should treat this as an allergic reaction instead"?  So far we've been lucky and I've gone with MY gut-- but soon DD is going to have to be able to make these kinds of determinations for herself.   I don't even feel like I have done such a great job there, honestly.

[yelloww]

My ds has asthma, but it is allergy induced. If he had a full blow asthma attack, I'd stab him because it would be completely out of his normal situation for that to be happening. Therefore, in my mind, it would be an allergic reaction.

I also have a friend whose dh died from a bad asthma attack, leaving her to raise 4 kids on her own.  I'm a bit more sensitive to ds' asthma because of it. If he has a little bit of wheeze, it is because of pollen or pets and can be treated with an inhaler. Anything more than that gets me really suspicious that it is an allergic reaction.

The only exception to this is when he's around dogs. That kicks up the wheeze big time and it isn't related to anaphylaxsis.

[spacecanada]

I can completely relate, CMdeux!  I find myself realising how many allergic reactions I've had that I thought were asthma and I get scared.  It's only afterwards that I realise that it was probably an allergic reaction and not asthma.  Even for the person experiencing it, it can be very difficult to tell the difference.  The biggest thing I notice (in retrospect, and I'm trying to get better at this), is throat swelling.  Even just the tiniest bit of throat swelling is Epi for me, but it can be easily mistaken for low-grade wheezing or chest tightness, and that's what gets me every time.  Too many times.  Add in some panic and fear, and it's just a really bad situation to be in. 

Two months ago I drove myself to the fire department (I was in my car, two blocks away at the time) because I had one of these undetermined reactions that wasn't responding well to Salbutamol, but by the time I got there it was starting to resolve itself and they just monitored me for a while.  (Our local firefighters are also advanced life support paramedics.)

This is a question that may not really have an answer, and I hope one day that this will be talked about with more certainty.  On the safe side, I think it's better to Epi than not, especially with a history of super sensitive allergic reactions: aerosol, contact, traces of traces, etc.  Now, if only I could get my brain trained to think like that...