Standard Protocol for "Asthma Action Plans"

[Macabre]

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.

Thank you so much for posting that. I has posted "When Anaphylaxis Looks Like Asthma" a few years ago and then the link stopped working. It looks like they made it part of a larger document. Great to have.

I posted it because DS' anaphylaxis did present as asthma--that the inhaler did not abate. In fact, it got progressively worse. Then other symptoms appeared. We told the school nurse to epi him.  Improvement on all counts.  Then a biphasic reaction 8 hours later, including GI symptoms.

As a child I had to go to the ER about once a year for a number of years for horrible asthma attacks for which I got epinephrine.  I've almost used epi on myself when having bad asthma during bronchitis and flu--once time as recently as a month ago. 

I look for bluing of fingernail beds and lips.  There's a technical term for it--can't think of it right now.

[CMdeux]

cyanosis?

[Macabre]

Yes.

Violet! You're turning violet, violet!

http://youtu.be/mkH4UgIJRmA

[LinksEtc]

Well, I'm dropping the idea  .  Our allergist didn't go for the idea.  I felt so strongly that this was a good idea, that it could potentially save lives, but I'm not the expert.

I'll just document the general idea here & then let it go:

1.  Have a special version of asthma action plans for those also having FA

2.  After green zone box, if having resp symptoms:  If suspected allergen ingestion, sudden onset of severe asthma
symptoms following food ingestion, or other food allergy symptoms, then patient is instructed to follow the FA action plan
and use epinephrine.

3.  In red zone, for some patients, have some instructions for the use of epinephrine to catch those instances where anaphylaxis is being mistaken for asthma (example - contact reaction then hand in mouth).

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Anyway, for any readers of this thread, follow both the food allergy and asthma action plans given to you by your doctors.  I'm not
a medical professional.

[CMdeux]

Did the doc explain why s/he thought it wasn't something that could be parsed like that?

(I'm genuinely curious-- and I plan to ask OUR allergist as well, so at least we can compare notes about it.)

[LinksEtc]

She just said that there are better asthma meds now than epi & and that epi for asthma (if used) would generally be in a hospital setting.

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I'm not going to take this any further with any of my doctors, I can't.  I'm just going to talk with them about my dd.

However, what I want to say and I've tried so hard to make clear is that the epi on the asthma plan is not for asthma.  It's for anaphylaxis that the patient thinks is asthma. 

I  that you see the value of discussing this with your dr.  I  that you often seem to "get" my crazy ideas.

I've personally taken this as far as I can.

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ETA for CM - Here's a pic.

[LinksEtc]

Sorry to bump this ... I know I said I'm done with this ... my thoughts are not cooperating  .

I'm just going to save a few spots here so I can add more info if/when I come across articles, etc.

Of course, anybody is welcome to still post if they want.

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"Asthma mortality among Swedish children and young adults, a 10-year study."
http://www.ncbi.nlm.nih.gov/pubmed/18635346

An alarming finding was that 11 of the 37 deaths were probably caused by food allergy and for 8 subjects death was associated with exposure to pet dander. The death certificates were found to contain inaccuracies with 30% of those for whom asthma was reported as the underlying cause having died from other causes.

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"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 a further five children there was evidence of allergen exposure shortly prior to death – in four cases exposure to an animal or pet, and in one case exposure to nuts.

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"I wish I was the parent that was warned"
http://allergy.hyperboards.com/action/view_topic/topic_id/4014

Mike [Andrew's Dad] got his shoes on and started up the truck. But he was afraid to take the nebulizer off Andrew because he was really struggling to breathe and his lips were turning blue.

At first, we though it was just his asthma. They said "no, its anaphylactic shock." It makes me angry more than words can say. We were never told anything like this could happen.

[LinksEtc]

"Near-Fatal Asthma: What Have We Learned?"
http://publications.chestnet.org/data/Journals/CHEST/21977/1394.pdf

near-fatal asthma (NFA)

What was surprising was that patients with NFA reported more food allergies and onset of their episode following a visit to a bar, party, or restaurant.

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"Emergency management of anaphylaxis in children and young people: new guidance from the Resuscitation Council (UK)"
http://ep.bmjjournals.com/content/94/4/97.extract?related-urls=yes&legid=edpract;94/4/97

Published prevalence of anaphylaxis admissions should be interpreted with caution as an unknown number could be miscoded as severe asthma

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"Anaphylaxis"
Kim and Fischer Allergy, Asthma & Clinical Immunology 2011, 7(Suppl 1):S6
http://www.aacijournal.com/content/pdf/1710-1492-7-S1-S6.pdf

As mentioned earlier, patients with asthma, particularly
those with poorly controlled asthma, are at
increased risk of a fatal reaction. In these patients, anaphylaxis
may be mistaken for an asthma exacerbation
and inappropriately treated solely with asthma inhalers.
Therefore, if there are ongoing asthma symptoms in an
individual with known anaphylaxis, epinephrine should
be given [6].

[LinksEtc]

"Postmortem findings after fatal anaphylactic reactions"
http://jcp.bmj.com/content/53/4/273.full

In five of 16 deaths caused by nut allergy, the postmortem cause of death was given as asthma, despite other features of a generalised reaction noted in the clinical record. It is possible that many other acute asthma deaths in those with a history of food allergy might have been reactions to food. A recent study from Sweden has identified soy proteins as a possible cause of such reactions.18 This raises the question of which deaths should be classified as anaphylactic, and which asthmatic.

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"Combined Action Plans for Food Allergy And Asthma?"

http://www.asthmaallergieschildren.com/2012/05/02/combined-action-plans-for-food-allergy-and-asthma/

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"Lessons for management of anaphylaxis from a study of fatal reactions"
R. S. H. PUMPHREY
http://medicina.med.up.pt/im/trabalhos05_06/sites/Turma21/artigos%20-%20WEB/tiburcio%2017.pdf

Because all food-related reactions caused difficulty breathing, the paramedics commonly had difficulty deciding whether to use the protocol for anaphylaxis or for asthma. This led to delayed or inappropriate treatment that may have contributed to the fatality.

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I found this similar discussion at the old FAS board

http://allergy.hyperboards.com/action/view_topic/topic_id/17634

Grab her inhaler! That LOOKS like an asthma attack! Oh, oops . . . anaphylaxis:

I'm not sure if I'm allowed to quote from this old thread (anyone can edit if it's a problem), but I just agree so much with this!

12/31/10

I would like to see these standard action plans revised to make it very clear that anaphylaxis can look like an asthma attack. I also would like to see this information part of the "welcome packet" of standard information given to parents of children with both anaphylaxis and asthma.

[CMdeux]

... and see, when I see that, I'm not thinking "surprising" so much as deeply TROUBLING.

[TwoDDs]

Agreed.  I don't find that "surprising" at all.  But, I'm not a doctor.

[LinksEtc]

If doctors can't always tell the difference between FA/anaphylaxis & asthma, it seems pretty clear that caregivers, patients, & nurses will sometimes have a hard time.

We always hear on the FA side, better safe than sorry, epi is a pretty safe drug.

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From the asthma side, a lot of doctors seem to have a much different perspective.  I wonder if some of this resistance has to do with the recent issue of epinephrine inhalers ... ex:

Epinephrine for Asthma (starting at 1:36)
Epinephrine for Asthma with Nancy Sander, Dr. Monica Kraft and Dr. Edward Kerwin

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Another unrelated thought on this general topic.  A lot of people with both asthma & FA have asthma symptoms quite often whereas allergic reactions often happen much more infrequently so I think there might also be a psychological element sometimes at play with respiratory symptoms where somebody's first instinct might be to think "asthma", not "FA".  Having an asthma plan targeted to those with FA would remind patients that they are dealing with 2 different possible scenarios.

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It's likely that if there were asthma plans like this, sometimes asthma would be mistaken for ana, but I'd personally rather have that for my dd than having ana mistaken for asthma since epi will help with both.  Possible unnecessary trip to ER compared to 

[LinksEtc]

I just wanted to say this one last time, especially for any newbies,  please follow the food allergy and asthma action plans given to you by your doctors.  Also, for food allergy reactions, it is important to remember this (bold mine):

"The benefits of epinephrine almost always outweigh the risks, but there's a reluctance to use it. Patients get palpitations, they might get a headache, their heart rate goes up, but it's a potentially life-saving treatment."

"Anaphylaxis Death Rate Down, but Epinephrine Use Poor"
http://www.medscape.com/viewarticle/780414

Talk with your doctors about any questions or concerns you are having.

[CMdeux]

   ALWAYS worth repeating. 

[LinksEtc]

Just adding a few more spots here.

This issue has activated my stubborn (and I hope not too annoying) side

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"Sudden Collapse In An Athlete"
http://www.amssm.org/sudden-collapse-in-an-ath-csa-35.html

With a past medical history of asthma, she thought she was having and asthma exacerbation and used her albuterol inhaler multiple times without relief of dyspnea

She was immediately given epinephrine 0.3 mg intramuscularly (into the thigh) and immediately regained consciousness with prompt resolution of dyspnea

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http://www.aaaai.org/ask-the-expert/Comparison-of-injected-epinephrine-and-inhaled-alb.aspx

Do you think IM or SC epinephrine should be added to school nurse treatment protocols for severe asthma epidoses that are not improving after albuterol administration (in addition to the nurse calling 911).

having epinephrine available as a backup is not a bad idea in case of poor inhalation technique, but it is not necessary to have injected epinephrine available for the treatment of asthma with proper inhaltion technique. Early studies (an example is copied below for your convenience) showed that the injection of epinephrine offered very little in addition to the inhalation of beta-adrenergic agents for the therapy of asthma

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"Parents seeking millions against school district for asthma attack death"
http://www.thenewstribune.com/2009/03/08/650722/parents-seeking-millions-against.html

Larson's orders don't stipulate the EpiPen must be used in an asthma attack, but the family's attorney, Thaddeus Martin, believes it would have saved her life.

As the four adults tried to get the child to relax, one of them gave Mercedes doses from an inhaler "telling Mercedes to try and hold it in"

Re: Follow up to Bethel Student who died from asthma attack



http://www.asthmaallergieschildren.com/2013/09/28/nasal-epinephrine-good-idea-or-not/

The great thing about epi is that if there's a caregiver present it doesn't depend on the status of the patient.  You deliver the drug to the thigh muscle and the body itself does all the work.