Standard Protocol for "Asthma Action Plans"

[LinksEtc]

"Food Intolerance and childhood asthma: what is the link?"
http://www.ncbi.nlm.nih.gov/pubmed/17523696

Asthma alone as a manifestation of a food allergy is rare and atypical. Less than 5% of patients experience wheezing without cutaneous or gastrointestinal symptoms during a food challenge.

* Just a quick note from me - conditions during an OFC with expert allergists closely monitoring symptoms are a lot different than normal everyday conditions with non-expert patients/caregivers having to decide how to recognize & treat a reaction.

Also, although this presentation may be atypical, it is not insignificant.

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http://community.kidswithfoodallergies.org/topic/when-anaphylaxis-looks-like-asthma

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House CallAug/Sep 2013 Issue
By Michael Pistiner, MD, MMSC, Jennifer LeBovidge, PHD, and Anaphylaxis Canada

http://www.livingwithout.com/issues/4_27/housecall-aug-sep13-3388-1.html

I'm worried about confusing asthma symptoms with anaphylaxis. What if I give my child the wrong medication?

[LinksEtc]

Here I'll put a few threads from our board ...


Newly Dx-Sesame, Sunflower, Flax, Wheat, Eggs

I wonder if I should ask for some type of inhaler??? Accidental exposure to Sunflower and Sesame bring on the wheezing and feeling like I cant catch my breath big time(obviously other symptoms too) Would that be something to help? Would I use it before or after the epi or in lieu of??? I hate to sound stupid but I would rather ask now and know. 

New to Allergies

Connecting "FA Action Plan" with "Asthma Action Plan"

[LinksEtc]

Good experiences with allergists and staff

Asthma as anaphylaxis:  again, any asthma that doesn't "fit" the usual pattern (for someone like my DD, who has pretty stable asthma) needs to be viewed with deep suspicion, and even moreso if she has been anywhere where there is food within the preceding hour or two.  I did laugh and remind him that this means anytime we've left the house.

That's the pattern, basically-- that "regular" asthma responds to rescue meds pretty well, and allergy-driven asthma does not.

My daughter's asthma has shifted slightly (worsened, actually, at least in frequency) in the past year or so.  We were aware that this could happen during adolescence, though obviously we aren't pleased about it.  She probably uses rescue meds 2-6 times a month even without illness or allergy being in the picture.

We are much better about checking peak flows as a result.  That's helpful in some respects, since we know what a 10% or 20% decrease in peak flows looks like, and she knows very well what it feels like. 

We also are quite aggressive about pre-medicating in any situation where an impairment is likely-- before exercise, before general anesthesia, etc.

So we have a sort of decision tree-- but not an "action plan" so to speak.  Not the way that we do with food allergy. 

But I have  lot clearer picture of when to transition from the one to the other now, and so I'm happy about that. 

Basically, the decision tree re: breathing problems of any kind is:

Possible allergen exposure?

Y/likely?  try ONE administration of albuterol-- and if it helps, observe, if not, proceed to allergy action plan-- aggressively.  Use Epi.

N/unlikely? try up to TWO administrations of albuterol (5-10 min apart), if impairment isn't significantly better, proceed to allergy action plan and watch carefully.  If impairment worsens, use EPI.

Other factors which change things slightly include:

a) ease of access to EMS (the more difficult, the more aggressive we'll want to be)
b) overall 'atopic' context-- that is, how reactive has she been recently, how much allergen load currently, etc.

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CM,

Regarding this ...

So we have a sort of decision tree-- but not an "action plan" so to speak.  Not the way that we do with food allergy. 

But I have  lot clearer picture of when to transition from the one to the other now, and so I'm happy about that. 

I have no doubt that you are on top of this without a written plan, but as your dd gets older and is not around you as much, do you still feel comfortable not having it written down for your dd and the people she may be with in case of a bad reaction?  I'm wondering even if having copies of the individualized asthma & allergy plans stored at MedicAlert might make sense for some (if that's something MedicAlert would do) ... it might convince first responders & ER docs the path that might be best for the particular patient involved.

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This isn't directed at CM ... just seemed to fit here.

http://www.cdc.gov/asthma/actionplan.html

All people with asthma should have an asthma action plan. An asthma action plan (also called a management plan) is a written plan that you develop with your doctor to help control your asthma.

ETA article against using plans:
Re: General asthma info & links

[LinksEtc]

Emerg Med J. 2013 Oct;30(10):878. doi: 10.1136/emermed-2013-203113.30.
Does anaphylaxis masquerade as asthma in children?
http://www.ncbi.nlm.nih.gov/pubmed/24014724

Anaphylaxis is under-reported in emergency settings and the potential for diagnostic confusion with acute asthma has been reported, especially in children who experience predominantly respiratory symptoms.

The results support the conclusion that some cases of anaphylaxis are unidentified and managed as acute asthma in children. The local frequency was estimated at 4.1% of children admitted to PICU but larger prospective multi-centre studies are required to better define the true prevalence nationally.

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http://clinicaltrials.gov/show/NCT01705964
University of Louisville

Project Aim: To determine if intramuscular epinephrine is an effective adjunct to inhaled bronchodilators (β2 agonists) for children with severe asthma exacerbation.

I wonder if they will keep track of which kids have FA.

[LinksEtc]

http://allergicliving.com/index.php/2010/07/02/readers-story-use-the-darn-needle/

When he was 7, a cheese slice touched his food. He didn't eat the cheese slice – it just touched his food. Sudden asthma attack. Albuterol and antihistamines barely made a dent this time. We rushed him to the doctor where he was given a shot of epinephrine and steroids. We had an EpiPen with us – we didn't use it because we were looking for more than asthma. Big mistake. We were lucky his symptoms turned around.

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"Allergy Frequently Asked Questions"
http://allergicliving.com/index.php/faq/

The CSACI says: "In cases where an anaphylactic reaction is suspected, but there is uncertainty whether or not the person is experiencing an asthma attack, epinephrine should be used first (e.g. before a puffer). Ephinephrine can be used to treat life-threatening asthma attacks as well as anaphylactic reactions."

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"Anaphylaxis Goes Unrecognized"
http://allergicliving.com/index.php/2010/07/02/food-allergy-anaphylaxis-goes-unrecognized/

Despite anaphylaxis becoming more common, it is under recognized

The reason is: it's not so easy to recognize

She notes that breathing problems can cause confusion over whether a person is suffering from anaphylaxis or an asthma attack.

[LinksEtc]

"Quandaries in prescribing an emergency action plan and self-injectable epinephrine for first-aid management of anaphylaxis in the community"

http://www.jacionline.org/article/S0091-6749(05)00017-5/fulltext


Below is just a hypothetical example ...they aren't advocating any specific course of action.
 
I added some bolding below.

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Seven-year-old child with clinical history of milk allergy (hives, vomiting) experiences sudden coughing and wheezing 15 minutes after a presumably milk-free lunch at a friend's house; has no rash or other symptoms.

Pro—inject immediately: safety of lunch uncertain, up to 10% of individuals with anaphylaxis have no skin signs, presentation of anaphylaxis varies from episode to episode in the same individual; treating anaphylaxis only with albuterol could have tragic consequences; low risk of side effects from SIE.

Con—inject immediately: for possible asthma exacerbation, try albuterol MDI first.

[LinksEtc]

Asthma and Food Allergies: What Parents Need to Know
Thursday, October 17, 2013 1:00 PM - 2:00 PM EDT
https://www4.gotomeeting.com/register/760226623

Join us with guest speaker David Stukus, MD, a Medical Advisor to KFA. Dr. Stukus is an Assistant Professor of Pediatrics in Allergy/Immunology at Nationwide Children's Hospital in Columbus, Ohio.

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http://community.kidswithfoodallergies.org/topic/asthma-and-food-allergies-what-you-need-to-know

Some of the topics that will be covered:

How can you tell asthma from food allergy?

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Well, it was a really nice & informative presentation .... the Dr was very knowledgeable, seemed nice, & has a sense of humor (ewww to the dust mite pic & lol at the epi, epi, epi slide) ....

but alas, no comments on the specific ideas in this thread (special versions of asthma plans for those also having FA), which was my ? ....
seems there were lots of ?'s.

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http://community.kidswithfoodallergies.org/blog/asthma-and-food-allergy-diagnosis-treatment-prevention-video-and-resources

[LinksEtc]

Just some late night rambling of thoughts ...

What is the downside of having special versions of asthma plans targeted to those also having FA? 

Yes, some coordination/communication between docs (ex - pulmo & allergist) might be necessary, but I don't see that as a bad thing.

Since the asthma plan would refer the patient to the "food allergy action plan" in certain cases, this would be an additional opportunity to check that the patient has in fact been given a FA plan.

Just like FA plans have different options for different patients (ex - epi if ingestion but no symptoms option) ... the asthma plan could be set up different ways .... (ex - sudden symptoms after eating ... do you try the albuterol 1st or not).

What I feel strongly about from a patient perspective is that docs have to write this stuff into the plans.  Something is missing from the plans when, in support groups like this, we keep having to explain the issue to newbies & we keep having to refer to that "When Anaphylaxis Looks Like Asthma" article.

We should be able to give schools (etc) copies of the "food allergy action plan" & "asthma action plan" and not have to worry that the wrong plan will be followed.  Why are we telling nurses that most will never need to give epi (http://www.nhlbi.nih.gov/health/prof/lung/asthma/sch-emer-actplan.pdf)?  Should we not be saying that when in doubt (for this special population with both FA & asthma), give epi?

[LinksEtc]

"Fatal and Near-Fatal Asthma in Children: the Critical Care Perspective"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402707/

Among all cases, 76 (29%) had a documented non-food allergy and 51 (20%) had a food allergy. Allergic exposure precipitated the admission in 19/102 (19%) of those with known allergies.

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"The natural history of fatal childhood asthma: a case from the Isle of Wight birth cohort"
http://eprints.soton.ac.uk/145831/

At the age of 11 years, despite apparent clinical stability and use of regular controller asthma therapy, she suffered a fatal acute asthma attack that may have been related to acute allergen exposure.

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"Fatal asthma in a child after use of an animal shampoo containing pyrethrin"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071005/

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I'm not sure how non-food allergies would fit into the equation.

[LinksEtc]

Hi to my good friend ET. 

Thank you 

[LinksEtc]

I thought I saved enough empty posts so that I wouldn't have to keep raising this thread, but I've run out of room again.  This time I'll save a lot, just in case.  Sorry to bump again.

Just reminding readers, yet again, please follow the "food allergy action plan" & "asthma action plan" given to you by your doctor(s).  If you have questions/concerns about issues raised in this thread, make sure to discuss them with your doctor(s).

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"Using Epinephrine to Treat Allergic Asthma"
http://itchylittleworld.com/2013/10/15/using-epinephrine-to-treat-allergic-asthma/

Today my son's allergist told me that I should use epinephrine ANY time my son starts to show signs of breathing distress after exposure to a known food allergen. And I should use it first, before Benedryl or Ventolin. And if he's going into an asthma crisis unrelated to food, to go ahead and use epinephrine as well.

The comments following that above blog post are also very interesting.

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FARE webinar - "Your Questions Answered: Anaphylaxis"
Dr. Robert A. Wood
http://blog.foodallergy.org/2013/11/15/your-questions-answered-anaphylaxis/

How can you distinguish between symptoms of anaphylaxis and other illnesses? (e.g., asthma attack, random hives, stomach cramps, or anxiety attack)

The symptoms can be identical. What we want to do is interpret the symptoms in the context of the overall situation and the chance that there's been a food exposure.

Could we write some of those criteria used to interpret "Lung" symptoms into the asthma plan?  If a FA parent tells somebody (like a family member or the school nurse) how to interpret the symptoms and which plan (asthma or allergy) to follow in a certain situation, what the parent says doesn't have the same credibility or permanency as what the doc(s) have actually written in the plans.  In an emergency, interpreting the symptoms (especially for non-medical caregivers) can be really tricky.  At some point, some of them could use a little kick - hey, get out of the asthma plan - you need to be looking at the food allergy plan.


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They are not suggesting this for everyone (personal docs must decide) ...

Children's Mercy - Kansas City
"Red Zone Treatment"
http://tinyurl.com/kgq6m64

If the patient is having a perceived life-threatening event, peripheral or central cyanosis, or worsening symptoms then the epinephrine should be administered and local emergency services contacted immediately.

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[LinksEtc]

Wow, this is the first asthma plan that I've seen that includes epinephrine as part of the standard form.

"STUDENT ASTHMA ACTION CARD"
http://dhss.alaska.gov/dph/wcfh/Documents/asthma_allergies/PDFs/AsthmaActionPlan.pdf

I authorize administration of an Epinephrine injection for my child if they have a severe asthma episode in which their prescribed asthma medication is not resolving their respiratory distress/failure.

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[LinksEtc]

I was thinking about comments CM made about the old FAAN food allergy action plan being confusing to some people.
FARE's new Food Allergy Action Plan

There may be a concern that having special asthma plans for those also having FA would be too confusing for patients/caregivers.  Writing it down might be a little confusing/surprising to some at first, but my opinion is that not having it written down is much more confusing/dangerous.

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http://www.allergyhome.org/handbook/table-of-contents/recognize-and-treat-allergic-reactions/epinephrine/

Many parents worry they might mistake anaphylaxis for an asthma attack.

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"Overview of Food Allergies and Anaphylaxis"
http://www.sde.ct.gov/sde/cwp/view.asp?a=2663&q=334642

Anaphylaxis may occur in the absence of any skin symptoms such as itching and hives. Fatal anaphylaxis is more common in children who present with respiratory symptoms or GI symptoms such as abdominal pain, nausea or vomiting. In many fatal reactions, the initial symptoms of anaphylaxis were mistaken for asthma or mild GI illness, which resulted in delayed treatment with epinephrine auto-injector.

Fatal anaphylaxis is more common in children with food aller­gies who are asthmatic, even if the asthma is mild and well controlled.

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[LinksEtc]

Dr Adam Fox talking to uk parliament.

Yes, yes, yes to what this doc said about needing a holistic approach for treating atopic kids.

Let me count the specialists we've seen for the atopic related stuff:  allergist, pulmo, derm, GI, ENT, & ped.  These docs often see things from their own corner of the atopic room & sometimes they fight, ok - let's say disagree, with each other.  When that happens, guess who gets to decide - yep, that would be me.  It's much nicer when they complement one another & communicate as a team.

My FAS passion these days - having special versions of asthma plans for those having both FA & asthma - in my non-medical opinion -  this is the type of specialty crossover that's needed.

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COMMON ERRORS IN INTERNAL MEDICINE
"ASTHMA OR ANAPHYLAXIS?"

http://www.fedprac.com/fileadmin/qhi_archive/ArticlePDF/FP/021050029.pdf

Food-induced anaphylaxis often is mistaken for severe status asthmaticus, and laboratory studies aren't helpful in differentiating the two.

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[LinksEtc]

For patients outside of a medical setting, the risk of epi overdose seems pretty low if given according to physician instructions because the amount is prefilled.  The med has saved countless lives.

A reminder:
"Food Allergies & Prescribed Injectable Epinephrine: Know. Practice. Carry. Use."
http://www.asthmaallergieschildren.com/2012/12/09/food-allergies-prescribed-injectable-epinephrine-know-practice-carry-use/

Epinephrine is safe and the alternative is unthinkable. The side effects (e.g. higher heart rate, jitteriness, headache) usually last only minutes and subside with rest.[1] Timing is essential as delayed administration has been associated with fatalities or near-fatalities.

However, if this general idea of loosening the restrictions on epi (in cases where it is unclear whether dealing with asthma or anaphylaxis) were applied to medical settings where docs/nurses measure the dose, the below risks would have to be considered.

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"Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution."
http://www.ncbi.nlm.nih.gov/m/pubmed/20031267/

Epinephrine is indicated for various medical emergencies, including cardiac arrest and anaphylaxis, but the dose and route of administration are different for each indication. For anaphylaxis, it is given intramuscularly at a low dose, whereas for cardiac arrest a higher dose is required intravenously. We encountered a patient with suspected anaphylaxis who developed transient severe systolic dysfunction because of inappropriately received cardiac arrest dose, ie, larger dose given as an intravenous push.

The risk of error was amplified by the need for rapid decision making in critically ill anaphylactic patients.

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Anaphylaxis: A review and update
Jennifer Tupper, MD CCFP(EM) and Shaun Visser, MD CCFP(EM)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2954079/#!po=31.2500

The error rate of epinephrine administration causing potentially fatal adverse reactions in one study was reported to be 2.4%.8 One study suggested that prefilled syringes of 0.3 mg of 1:1000 epinephrine clearly labeled to be given IM for anaphylaxis would decrease the incidence of dosing errors.8

Different pediatric doses might be needed.

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Epinephrine injected incorrectly in hospital


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"Safety of epinephrine for anaphylaxis in the emergency setting"
http://www.wjem.org/upload/admin/201311/d095a4afd3dc3f7fc3baa8d33a54d10b.pdf

CONCLUSION: Epinephrine by intramuscular injection is a safe therapy for anaphylaxis but training may still be necessary in emergency care settings to minimize drug dosing and administration errors and to allay concerns about its safety.