Asthma and Allergy UNDERLYING PRINCIPLES THE ALLERGIC REACTION An allergic reaction results from antigen-antibody reaction on sensitized

mast cells or basophils, causing the release of chemical mediators. The reaction may be characterized by inflammation, increased secretions, and bronchoconstriction. Definitions
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Antigen a protein that stimulates an immune reaction, causing the production of antibodies. Antibody a globulin (protein) produced by B cells as a defense mechanism against foreign materials. Atopy a term that refers to the ability to produce immunoglobulin E antibodies to common allergens. Immunity: o Humoral the process by which B lymphocytes produce circulating antibodies to act against antigens. o Cell-mediated that portion of the immune system in which the participation of T lymphocytes and macrophages is predominant. Mast cell tissue cell similar to peripheral blood basophil and containing granules with chemical mediators. Basophil a leukocyte with large granules that contain histamine. Hypersensitivity reaction to an antigen after reexposure; there are four types; type I (immediate) and type IV (delayed) are considered allergic reactions.

Immunoglobulins Antibodies that are formed by lymphocytes and plasma cells in response to an immunogenic stimulus comprise a group of serum proteins called immunoglobulins.
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The abbreviation for immunoglobulin is Ig. Antibodies combine with antigens in lock-and-key style. There are five major classes of immunoglobulins. o IgM constitutes 10% of immunoglobulin pool; found mostly in intravascular fluid and primarily engaged in initial defense. o IgG major immunoglobulin that accounts for 70% to 75% of secondary immune responses and that combats tissue infection. o IgA 15% to 20% of immunoglobulins; predominantly found in seromucous secretions (such as saliva, tears) in which it provides a primary defense mechanism. o IgD less than 1% of immunoglobulin pool; found on circulating B lymphocytes, but function is unknown. o IgE only a trace found in serum; attaches to surface membrane of basophils and mast cells; responsible for immediate types of allergic reactions.

Immunologic Reactions Immediate Hypersensitivity (Type I)

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Characterized by: o Allergic reaction Type I immediate hypersensitivity. During the initial exposure, T cells recognize foreign allergens and release chemicals to instruct B cells to produce immunoglobulin E (IgE). These antibodies attach themselves to mast cells. Upon reexposure, the allergen comes in contact with the IgE antibodies attached to mast cells, causing degranulation and release of chemical mediators. Occurs immediately after contact with the antigen. Causes synthesis and release of chemical mediators. Example: anaphylaxis, allergic rhinitis, urticaria.
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Products of Immediate Hypersensitivity (Chemical Mediators)

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Histamine- a bioactive amine stored in granules of mast cells and basophils. Leukotrienes- a newly synthesized potent bronchoconstrictors; cause increased venous permeability. Prostaglandins- potent vasodilators and potent bronchoconstrictors. Platelet-activating factor- has many properties; causes the aggregation of platelets. Cytokines- control and regulate immunologic functions (eg, interleukins, tumor necrosis factor). Proteases-enzymes, such as tryptase and chymase, increase vascular permeability. Eosinophil chemotactic factor of anaphylaxis causes an influx of eosinophils into the area of allergic inflammation.

Effects of Chemical Mediators and Their Manifestations

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Generalized vasodilation, hypotension, flushing. Increased permeability. o Capillaries of the skin edema. o Mucous membranes edema. Smooth muscle contraction. o Bronchioles bronchospasm. o Intestines abdominal cramps, diarrhea. Increased secretions. o Nasal mucous glands rhinorrhea. o Bronchioles increased mucus in airways. o GI increased gastric secretions. o Lacrimal tearing. o Salivary salivation. Pruritus (itching). o Skin. o Mucous membrane.

Delayed Hypersensitivity (Type IV)

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Characterized by a cell-mediated reaction between antigens and antigen-responsive T lymphocytes. Maximal intensity occurs between 24 and 48 hours. Usually consists of erythema and induration. Example: tuberculin skin test; contact dermatitis such as poison ivy.

ASSESSMENT AND DIAGNOSTIC TESTS EVALUATION OF THE PATIENT FOR ALLERGY Evaluation includes:
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The allergy history Physical examination based on patient presentation and specific allergy condition, usually skin, HEENT, chest. Skin testing Other tests as indicated for specific allergic conditions.

Skin Testing The purpose of skin testing is to identify antigens responsible for immediate hypersensitivity. The types of skin tests used in clinical allergy are epicutaneous (prick, puncture, or scratch) and intradermal methods. The skin test remains unequaled as a sensitive, specific, and effective test for the diagnosis of allergies. PROCEDURE GUIDELINES Epicutaneous Skin Testing EQUIPMENT
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Antigens for testing Controls o Positive histamine 1 mg/mL

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Negative glycerol saline Disposable pricking devices (sterile needles or lancets) Alcohol swabs Paper tissues Skin marking pencil Millimeter ruler Tourniquet Epinephrine 1:1000 aqueous solution for injection for emergency use
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PROCEDURE Nursing Action Rationale Preparatory phase 1.Explain the procedure to the patient. Ask if 1.Oral antihistamines taken 72 hours before skin testing patient has taken antihistamines in the past 72 are likely to prevent a reaction from occurring. hours. Desloratadine can affect skin testing up to 7 days. 2.Prepare the site (volar surface of forearm or 2.The forearm is usually preferable because in the event back) by cleansing with alcohol. of a significant local or systemic reaction, a tourniquet may be placed proximal to the skin test to slow the diffusion of the antigen into the circulation. 3.Mark the test sites with a skin marking pencil 3.Sites need to be spaced appropriately so that reactions approximately 3-4 cm apart. will remain distinct from one another, thus allowing an accurate reading. Implementation phase 1.Apply positive (histamine) and negative 1.Because of interpatient variability in cutaneous (glycerol saline) controls next to the appropriate reactivity, it is necessary to include positive and markings. Introduce the tip of the pricking negative controls whenever skin testing is performed. A device at a 15- to 20-degree angle through response to the positive control confirms an each drop, lifting up and tenting the skin until immunologic ability to react. A response to the negative control indicates reactivity to the diluting solution or the point pops loose without causing any mechanical trauma. Care must be taken to prevent bleeding. Discard pricking device after each puncture. cross-contamination between antigens. 2.Apply small drops of antigens next to the skin 2.Large drops may run and cross-contaminate, affecting markings and prick the drops as described interpretation. above. 3.Instruct the patient not to scratch the test area 3.It is normal for sensitive individuals to have a pruritic during the 15-minute waiting interval before the sensation at the testing site because of the histamine reactions are graded. released by the mast cells. 4.Observe the patient closely for signs of 4.General systemic or anaphylactic reactions are rare, impending anaphylaxis (such as itching, but do occur. If suspected, apply tourniquet above test flushing, lump in throat). site and administer 0.3 mL epinephrine 1:1000 subcutaneously. Follow-up phase 1.Fifteen minutes after pricking the antigens, 1.Amount of induration indicates the extent of reaction, measure the diameter of induration (wheal) and but erythema is noted as well. erythema (flare) in two perpendicular axes through the center of the reaction; record in millimeters. 2.Document the procedure, test results, patient tolerance, and any other pertinent observations. PROCEDURE GUIDELINES Intradermal Skin Testing EQUIPMENT
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Antigens for testing Controls o Positive histamine 0.1 mg/mL o Negative human serum albumin/saline 1-mm syringes with 26G or 27G intradermal needle Alcohol swabs Paper tissues Skin-marking pencil Millimeter ruler

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Tourniquet Gloves Epinephrine for emergency use

PROCEDURE Nursing Action Rationale Preparatory phase 1.Explain the procedure to the patient. Ask if patient has taken 1.Oral antihistamines taken 72 hours antihistamines in the past 72 hours. before skin testing are likely to prevent a reaction from occurring. 2.Prepare the site (volar surface of forearm or upper arm) by 2.Allowing alcohol to dry ensures cleansing with alcohol. Allow to dry. antisepsis. 3.Mark the test sites with a skin marking pencil approximately 3- 3.Sites need to be spaced appropriately 4 cm apart. so that reactions will remain distinct from one another, thus allowing an accurate reading. Implementation phase 1.Using sterile technique, draw up 0.05 mL of each testing 1.Gloves should be worn when there is material. All bubbles must be carefully expelled to avoid any possibility of exposure to blood or splash reactions, which reduce precision. While body fluids. Only small amount needs to be deposited into skinenough to wearing gloves, place syringe at a 10- to 15-degree angle to the skin with the bevel up. Stretch the skin taut and insert 0.02 raise a bleb. mL of the positive and negative controls. The bevel should penetrate the skin entirely and end between the layers of skin. A bleb approximately 2 mm in diameter should be produced. 2.Inject approximately 0.02 mL of test antigens intradermally 2.To avoid antigen and microbial next to the skin markings. A different syringe and needle must contamination. be used for each antigen. (A) Intradermal injection producing a wheal. (B) Measuring area of induration. 3.Instruct the patient not to scratch the test area during the 15- 3.It is normal for sensitive individuals to minute waiting interval before the reaction is graded. have a pruritic sensation at the testing site because of the histamine released by the mast cells. 4.Observe the patient closely for signs of impending anaphylaxis 4.There is an increased possibility of (itching, flushing, lump in throat). anaphylactic reactions with intradermal 5.Fifteen minutes after applying antigens, measure the diameter skin testing. If suspected, apply of induration (wheal) and erythema (flare) in two perpendicular tourniquet above test site and axes through the center of the reaction and record in administer 0.3 mL (0.01 mL/kg in millimeters. children < 30 kg) epinephrine 1:1000 subcutaneously. Follow-up phase 1.Document the procedure, test results, patient tolerance, and any other pertinent observations. 2.Monitor for the following complications during and following 2.Any significant reaction may be anxietytesting: provoking for the patient, but anaphylaxis occurs suddenly and may be life-threatening. Local Reactions unusually large 4+ reactions a. Apply prescribed steroid cream to affected area. b. If no relief, administer prescribed oral antihistamine. Vasovagal Reactions fainting episode a. Monitor vital signs. b. Reassure the patient. c. Finish skin testing if possible. Systemic Anaphylaxis a. Stop testing and apply tourniquet above skin testing site.

b. Administer epinephrine subcutaneously. c. Alert physician or emergency responders. Epicutaneous (Prick) Method
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Advantages: o Safe less chance for anaphylaxis because of minimal systemic absorption. o Efficient results within 15 minutes. o Little discomfort to the patient. Disadvantages: o Less sensitive than the intradermal method. o Old or thick, leathery skin decreases reactivity. o Drops have a tendency to run together, which would affect the accuracy of the test.

Intradermal Method
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Advantages: o More sensitive than prick testing. Disadvantages: o Less specific than prick testing. o Increased possibility for anaphylactic reactions. o Requires more time and skill to perform. o Increased discomfort to the patient.

Radioallergosorbent Test The radioallergosorbent test (RAST) measures the allergen-specific IgE antibodies in serum samples after panel of allergens have been added to samples. Nursing and Patient Care Considerations
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Allergy testing without the risk of causing severe allergic reaction. Obtain adequate venous blood for each allergen to be tested. A positive RAST result depends on the standards for that particular laboratory. Arrange for a follow-up visit for the patient with the health care provider to discuss test results

GENERAL PROCEDURES AND TREATMENT MODALITIES IMMUNOTHERAPY Immunotherapy is the desensitization of the immune system to a known allergen that causes IgE, type I (immediate) hypersensitivity. It is indicated for significant symptoms of allergic rhinitis and asthma that cannot be controlled by avoidance of the allergen. Although immunotherapy is not a cure, it gives relief to most people. Considerable compliance and time commitment are essential for successful therapy. Features of Immunotherapy
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Specific allergens are identified by skin testing or RAST. Serial injections are begun that contain extracts from identified allergens (allergy vaccine). Initially, small amount of dilute allergy vaccine is given, usually at weekly intervals. Amount and concentration are slowly increased to maximum tolerable dose. The maintenance dose is injected every 2 to 4 weeks for a period of several years to achieve maximal benefit. Several allergens are now standardized (dust mite, cat, grass pollens).

Precautions and Considerations

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The danger of anaphylactic reaction exists after injection. o Should be given only in health care facility with epinephrine (Adrenalin), trained personnel, and emergency equipment available. o Patient should remain in office for 30 minutes after injection, after which the risk of anaphylaxis is greatly reduced. o If large, local reaction (erythema, induration) occurs after an injection, the next dose should not be increased without checking with prescribing health care provider because a systemic reaction may occur.

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If several weeks are missed, dosage may need to be decreased to prevent a reaction. Medication, such as antihistamines and decongestants, should be continued until significant symptom relief occurs (may take 12 to 24 months). Environmental controls should be maintained to enhance effectiveness of therapy.

STANDARDS OF CARE GUIDELINES IMMUNOTHERAPY To perform immunotherapy or allergy testing, have epinephrine 1:1,000 available with a 1-cc syringe and a subcutaneous needle.
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Make sure that the patient remains under observation for at least 30 minutes after injection and assess for local reaction and respiratory distress before the patient leaves. If a significant reaction occurred after the last injection or if the patient is late for his or her dosage, follow written protocol for those cases or call the patient's health care provider for instructions. Be prepared to inject 0.3 to 0.5 mL of epinephrine subcutaneously as directed by health care provider present or institutional protocol if signs of anaphylaxis develop. Call for immediate help and transfer to an acute care facility.

Footnote This information should serve as a general guideline only. Each patient situation presents a unique set of clinical factors and requires nursing judgment to guide care, which may include additional or alternative measures and approaches. ALLERGIC DISORDERS ANAPHYLAXIS Anaphylaxis is an immediate, life-threatening systemic reaction that can occur on exposure to a particular substance. It is a result of a type I hypersensitivity reaction in which chemical mediators released from mast cells affect many types of tissue and organ systems. NURSING ALERT With immunotherapy (allergy shots), the risk of systemic reaction is always present. Skin testing can also result in systemic reactions. Have epinephrine 1:1,000 available during these procedures (with syringe and tourniquet) and have patient remain in office or clinic for at least 30 minutes after administration. Pathophysiology and Etiology
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May be caused by: o Immunotherapy. o Stinging insects. o Skin testing. o Medications. o Contrast media infusion. o Foods. o Exercise. o Latex. Release of chemical mediators results in massive vasodilation; increased capillary permeability, bronchoconstriction, and decreased peristalsis.

Clinical Manifestations
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Respiratory laryngeal edema, bronchospasm, cough, wheezing, lump in throat. Cardiovascular hypotension, tachycardia, palpitations, syncope. Cutaneous urticaria (hives), angioedema, pruritus, erythema (flushing). GInausea, vomiting, diarrhea, abdominal pain, bloating.

PROCEDURE GUIDELINES Giving an Allergy Injection EQUIPMENT

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Patient's individualized allergy vaccine 1 mL syringe 25G to 27G - to 5/8-inch needle

Alcohol sponges

NURSING ALERT Because of the risk of anaphylaxis, have epinephrine (Adrenalin) 1:1000 readily available for injection, as well as oxygen, parenteral diphenhydramine, and I.V. supplies. PROCEDURE Nursing Action Rationale Preparatory phase 1.Check record and ask patient about reaction to 1.Local erythema and induration may have occurred last injection. Note how many weeks since last during observation period or later. shot. 2.Check order for prescribed dosage and any 2.Significant reaction (greater than 2-3 cm and lasting 24 special instructions based on reaction history. hours) may require injection at same or lower dose. Missed weeks may require dosage adjustment. 3.Draw up dose, checking strength of allergy 3.Vaccine will be replaced periodically with a stronger vaccine and amount (usually 0.1-0.5 mL) preparation. 4.Verify correct dose for the patient. 4.Incorrect vaccine or dose may cause anaphylaxis. Performance phase 1.Select the appropriate site for subcutaneous 1.Because injections usually given only once per week, no injection; usually, the midlateral upper arms. If need to use abdomen or thighs. Using different arms for two injections are necessary, give in opposite two injections allows for determining which vaccine may arms. have caused reaction if one occurs. 2.Wear gloves if pressure is applied to patient's 2.Will prevent contact with patient's blood. arm. 3.Cleanse site with alcohol and allow to dry. 3.Disinfects skin. 4.Grasp upper arm with nondominant hand so 4.Secures arm and subcutaneous tissue beneath outer that tissue is elevated slightly. skin. 5.Insert needle at 45- to 90-degrees, depending 5.Thickness of subcutaneous tissue varies among on thickness of subcutaneous tissue at the individuals. site. 6.Aspirate for blood return, and if none occurs, 6.If blood enters syringe, dispose of it and begin again inject serum. rather than injecting into a blood vessel. 7.Withdraw syringe, cover site with alcohol 7.Follow institution policy; do not resheath needle. sponge, and dispose of needle and syringe. Check site for bleeding or bruising. Follow-up phase 1.Have patient wait 30 min before leaving the 1.Significant local or systemic reaction may occur; most facility. Check for local reaction periodically likely with increased dose or new vaccine vial. and tell patient to report any sudden swelling, itching, or respiratory difficulty. 2.Record amount and concentration of vaccine, 2.Flow sheet serves as official documentation of site given, and appearance of site after 30 medication given and may be reviewed by allergist when minutes. evaluating therapy. 3.Dismiss patient with instructions on who to call 3.May call allergist or primary care provider, or go to if reaction occurs and when to return for next emergency room if systemic reaction occurs. injection. DRUG ALERT Before you administer any drug, ask if the patient has ever had a reaction to it. Do not rely on the chart alone. Management Prompt identification of signs and symptoms and immediate intervention are essential; a reaction that occurs quickly tends to be more severe. Immediate Treatment
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A tourniquet is applied above site of antigen injection (allergy injection, insect sting, etc.) or skin test site to slow the absorption of antigen into the system. Epinephrine (Adrenalin) 1:1,000, adolescents and adults: 0.3 to 0.5 mL, children 0.01 ml/kg is injected subcutaneously or I.M. into opposite arm; may be repeated every 15 to 20 minutes if necessarycauses vasoconstriction, decreases capillary permeability, relaxes airway smooth muscle, and inhibits mast cell mediator release. Have patient lie with legs elevated. Monitor vital signs continuously.

Subsequent Treatment
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An adequate airway is established and albuterol is administered by inhalation as needed. Hypotension and shock are treated with fluids and vasopressors. Additional bronchodilators are given to relax bronchial smooth muscle. Histamine-1 (H1) antihistamines, such as diphenhydramine (Benadryl), and possibly H2 antihistamines, such as ranitidine (Zantac), are given to block the effects of histamine. Corticosteroids are given to decrease vascular permeability and diminish the migration of inflammatory cells; may be helpful in preventing late-phase responses.

Complications
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Cardiovascular collapse. Respiratory failure.

Nursing Assessment
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Quickly assess airway, breathing, and circulation (ABCs) if severe presentation and intervene with cardiopulmonary resuscitation as appropriate. When ABCs are stable, assess vital signs, degree of respiratory distress, and angioedema. Obtain a history of onset of symptoms and of exposure to allergen.

Nursing Diagnoses
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Ineffective Breathing Pattern related to bronchospasm and laryngeal edema Decreased Cardiac Output related to vasodilation Anxiety related to respiratory distress and life-threatening situation

Nursing Interventions Restoring Effective Breathing

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Establish and maintain an adequate airway. o If epinephrine has not stabilized bronchospasm, assist with endotracheal intubation, emergency tracheos-tomy, or cricothyroidotomy as indicated. o Continually monitor respiratory rate, depth, and breath sounds for decreased work of breathing and effective ventilation. Administer nebulized albuterol or other bronchodilators, as ordered. Monitor heart rate (increased with bronchodilators). Provide oxygen via nasal cannula at 2 to 5 L/minute or by alternative means, as ordered. Administer I.V. corticosteroids as ordered.

Increasing Cardiac Output

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Monitor blood pressure by continuous automatic cuff, if available. Administer rapid infusion of I.V. fluids to fill vasodilated circulatory system and raise blood pressure. Monitor central venous pressure (CVP) to ensure adequate fluid volume and to prevent fluid overload. Insert indwelling catheter and monitor urine output hourly to ensure kidney perfusion. Initiate and titrate vasopressor, as ordered, based on blood pressure response.

Reducing Anxiety
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Provide care in a quick, confident manner. Remain responsive to the patient, who may remain alert, but not completely coherent because of hypotension, hypoxemia, and effects of medication. Keep family or significant others informed of patient's condition and the treatment being given. When patient is stable and alert, give simple, honest explanation of anaphylaxis and the treatment that was given.

Community and Home Care Considerations

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Make sure that patient who has experienced anaphylaxis or severe local reactions obtains a prescription for self-injectable epinephrine (Epi-Pen) to have with him at all times. o Instruct the patient and family members in the injection technique upon exposure to known antigen or at the first signs of a systemic reaction. o Provide patient with information on epinephrine, including drug action, possible adverse effects, the importance of prompt administration at the first sign of a systemic reaction, and replacement of outdated syringe. Even if treatment is given successfully at home, the patient should follow up with the health care provider immediately. Make sure that the patient with history of anaphylaxis has access to emergency medical system and does not spend time alone if risk of reaction is present.

Patient Education and Health Maintenance

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Teach the patient at risk for anaphylaxis about the potential seriousness of these reactions. Educate patient to recognize the early signs and symptoms of anaphylaxis. Persons allergic to bee stings should avoid wearing brightly colored or black clothes, perfumes, and hair spray. Shoes should be worn at all times. For exercise-induced anaphylaxis, patient should exercise in moderation, preferably with another person, and in a controlled setting, where assistance is readily available. Instruct patient to wear a MedicAlert bracelet at all times. For potential drug allergies, teach the patient: o Read labels and be familiar with the generic name of the drug thought to cause a reaction. o Discard all unused drugs. Make sure any drug kept in the medicine cabinet is clearly labeled. o Familiarize yourself with drugs that may cross-react with a drug to which you are allergic. o Always know the name of every drug that you take. o Clear all herbals and neutriceuticals with health care provider. Advise patient with a known sensitivity to a food product to be extremely careful about everything he eatsallergen compounds may be hidden in a preparation (such as caseinate, lactal bumin). Advise that if food is associated with exercise-induced anaphylaxis, wait at least 2 hours after eating to exercise.

Evaluation: Expected Outcomes

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Respirations unlabored with clear lung fields, minimal wheezing Blood pressure and CVP within normal range; urine output adequate Responsive and cooperative

ALLERGIC RHINITIS Allergic rhinitis is an inflammation of the nasal mucosa caused by an allergen that affects 10% to 25% of the population. Pathophysiology and Etiology
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Type I hypersensitivity causes local vasodilation and increased capillary permeability. Caused by airborne allergens. IgE-mediated inflammatory process is now believed to be the same disease process for asthma and allergic rhinitis. Allergic rhinitis was formerly classified as seasonal or perennial; current classifications are intermittent or persistent. o Intermittent- symptoms present less than 4 days per week and less then 4 weeks per year o Persistent- symptoms present more than 4 days per week and more than 4 weeks per year Severity is classified as mild (no interference with daily activities or troublesome symptoms) or moderate-severe (presence of at least one: impaired sleep, daily activity, work, or school; troublesome symptoms).

Clinical Manifestations
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Nasal- mucous membrane congestion, edema, itching, rhinorrhea with clear secretions, sneezing. Eyes-edema, itching, burning, tearing, redness, dark circles under eyes (allergic shiners). Ears-itching, fullness. Other-palatal itching, throat itching, nonproductive cough.

Diagnostic Evaluation
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Skin testing-confirms a hypersensitivity to certain allergens. Nasal smear-an increased number of eosinophils suggests allergic disease. RAST-positive test result for offending allergens. Rhinoscopy-allows better visualization of the nasopharynx; useful to rule out physical obstruction (septal deviation, nasal polyps). Evaluation for asthma.

Management Avoidance
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Patient should minimize contact with offending allergens, regardless of other treatment. Patient may be instructed to reduce dust mite exposure by encasing bed pillows and mattress in allergen-proof covering; however, studies have not shown that this alone improves symptoms. Use of allergen-proof bedding should be carried out in conjunction with broad environmental controls.

Medications: Acute Phase

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H1 antihistamines-block the effects of histamine on smooth muscle and blood vessels by blocking histamine receptor sites, thereby relieving the symptoms of allergic rhinitis (oral and topical preparations). o Older, possibly sedating antihistamines (diphenhydramine [Benadryl]; chlorpheniramine [Chlor-Trimeton]) are inexpensive, available over-the-counter (OTC), short acting, and effective. o Loratadine (Claritin, Alavert) is the first long-acting, nonsedating antihistamine sold OTC. o Newer, long-acting, nonsedating or less sedating antihistamines available by prescription include desloratadine (Clarinex), fexofenadine (Allegra), and cetirizine (Zyrtec) o Topical antihistamine nasal spray available by prescription (azelastine [Astelin]). Decongestants-shrink nasal mucous membrane by vasoconstriction; many available OTC and in combination with antihistamines, pain relievers, and anticholinergics. Anticholinergic agents-inhibit mucous secretions, act as drying agents. Topical eye preparations sold OTC reduce inflammation and relieve itching and burning.

Medications: Preventive Therapy

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Intranasal corticosteroids o Reduce inflammation of nasal mucosa. o Prevent mediator release. o Can be used safely every day o May be given systemically for a short course during a disabling attack. Intranasal cromolyn sodium (Nasalcrom)mast cell stabilizer; hinders the release of chemical mediators. Mast cell stabilizers now also are available as oral preparation cromolyn (Gastrocrom) and ophthalmic solution cromolyn (Crolom) and lodoxamide (Alomide). These medications are used before and during allergen season. Leukotriene receptor antagonists, including montelukast (Singulair) and zafirlukast (Accolate), are systemic agents used for asthma; these agents also reduce the inflammation, edema, and mucous secretion of allergic rhinitis.

Immunotherapy
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Regimen consists of administering subcutaneous injections of increasing amounts of an allergen to which the patient is sensitive to decrease sensitivity and reduce the severity of symptoms. Immunotherapy produces the following immunologic changes: o Production of IgG-blocking antibody that combines with antigen before it reacts with IgE antibodies. o May decrease IgE antibodies against specific antigens. o Modulation from Th2 to Th1 T lymphocytes. (Th2 associated with allergy). Possible adverse effects of immunotherapy. o Systemic reactionsanaphylaxis is rare, but potentially fatal. o Local reactionsconsist of erythema and induration at the site of injection.

NURSING ALERT Immunotherapy should not be given to patients who are actively wheezing or receiving betaadrenergic blockers. It would be difficult to reverse a systemic reaction, should one occur. Complications
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Allergic asthma. Chronic otitis media, hearing loss. Chronic nasal obstruction, sinusitis. Orthodontic malocclusion in children

Nursing Assessment
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Obtain history of severity and seasonality of symptoms. Inspect for characteristic tearing, conjunctival erythema, pale nasal mucous membranes with clear discharge, allergic shiners, and mouth breathing. Auscultate lungs for wheezing or prolonged expiration characteristic of asthma.

Nursing Diagnoses
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Ineffective Breathing Pattern related to nasal obstruction

Nursing Interventions Facilitating Normal Breathing Pattern

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Reassure patient that suffocation will not occur because of nasal obstruction; mouth breathing will occur. Use intranasal saline and increase oral fluid intake to prevent drying of mucous membranes and increased insensible loss through mouth breathing. Administer and teach self-administration of antihistamines, decongestants, intranasal corticosteroids, and other medications, as directed. o Instruct patients on proper use of nasal inhalersclear mucus from nose first, exhale, flex neck to point nose downward, direct spray away from the nasal septum (toward the eye), activate inhaler, and gently sniff while releasing medication. o Warn patient to avoid driving or other situations that require alertness if sedating antihistamines, such as diphenhydramine (Benadryl) or chlorpheniramine (Chlor-Trimeton) have been prescribed. o Do not use OTC nasal decongestants for more than 4 to 5 days because their effect is short-term and a rebound effect, which causes nasal mucosal edema, commonly occurs.

PATIENT EDUCATION GUIDELINES Environmental Control for Allergic Rhinitis The following environmental modifications may help reduce symptoms of allergic rhinitis (hay fever):
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Encase pillows and mattress in allergen-proof covers. Wash all bed linens (mattress pad, sheets, blanket, comforter, and bedspread) in hot water weekly. Keep clothing in a closet with door shut or in dresser drawers that are kept closed. Use easily cleaned shades, blinds, and curtains. Avoid stuffed animals and other items that collect dust. Vacuum and damp-dust weekly; wear a mask while doing it. If you have severe symptoms of dust allergy, leave the house during cleaning. Allergic reaction is possible for about 30 minutes after vacuuming because dust mite feces and other allergens become airborne. Fine-filtering face masks may provide some protection. Eliminate upholstered furniture, carpets, and draperies. Use air conditioning and keep windows closed during high pollen and mold seasons to reduce antigen load indoors. Change furnace and air conditioner filters frequently. Using a high-efficiency air filtering system may help. Avoid smoking and smoke-filled areas. Avoid rapid changes in temperature. If you are allergic to animal dander, you should not have household pets. If pets are present in your household, keep them out of the bedroom and run a high efficiency particulate air filter (place on table).

Avoid mold growth by dehumidification (< 45% ambient humidity) and use of a fungicide in bathrooms, damp basements, food storage areas, and garbage containers. y Avoid outdoor activities when pollen or other pollutants are in the air.

DRUG ALERT Long-term use of nasal corticosteroids may cause nasal septum rupture. Teach patients to direct spray or aerosol away from septum. Patient Education and Health Maintenance
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Provide information on purpose, administration method, time frame of expected results, and possible risks involved (local reactions, anaphylaxis) with immunotherapy. Inform the patient that close observation for 30 minutes is essential after each injection. Alert patient to the possibility of a delayed reaction during immunotherapy that should be reported to the nurse or health care provider. Teach lifestyle and environmental changes to reduce exposure to allergens.

Evaluation: Expected Outcomes Decreased eye and nasal symptoms, mouth breathing; no complaints of dry mouth URTICARIA AND ANGIOEDEMA Urticaria (hives) may affect 25% of the population at some time. Angioedema is a similar lesion, but involves deep dermis and subcutaneous tissues. Urticaria and angioedema can occur individually or in combination. Pathophysiology and Etiology
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Acute urticaria: o Hives that last less than 6 weeks. o A detectable cause is usually determined. Chronic urticaria: o Hives that last 6 weeks or longer. o Up to 50% of cases may be autoimmune chronic urticaria with autoantibodies against high affinity IgE receptor or IgE o At least 50% are idiopathic Cause may be undetermined, or may include: o Ingested substances-food, food additives, drugs. o Infections-viral, bacterial, parasitic. o Physical factors-heat, sun, cold, pressure, emotional stress. o Insect stings.

Clinical Manifestations
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Raised, red, edematous wheals. Intense pruritus. May affect any body region. Diffuse swelling with angioedema, especially of the lips, eyelids, cheeks, hands, and feet. Symptoms may develop within seconds or over 1 to 2 hours and may last up to 24 to 36 hours.

Diagnostic Evaluation
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Laboratory serum tryptase is elevated in the acute phase, complement study results can be abnormal, total serum IgE elevated. Challenge testing to determine physical cause. o Exercise challenge. o Ice cube challenge. o Heat challenge. o Pressure challenge. o Dermographism present.

Management Acute urticaria

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Identification and elimination of causative factors.

Medications. o H1 antihistamines, such as diphenhydramine (Benadryl) and cetirizine (Zyrtec). o Epinephrine (Adrenalin) 1:1,000 (0.3 to 0.5 mL subcutaneously) for extensive urticaria, angioedema. o Corticosteroidslimited to severe cases; unresponsive to antihistamines.

Prolonged urticaria
y y

Avoid causative factors. Medications. o H1 antihistamines. o H2 antihistamines, such as ranitidine (Zantac), may be of some value. o Tricyclic antidepressants, such as doxepin (Adapen), given for antihistaminic effect. o Topical agents to relieve itching (moisturizer or oatmeal baths).

Complications
y y

Neurovascular impairment because of swelling. Occasionally edema of the larynx or bronchi may occur.

Nursing Assessment
y y y

Assess for time frame during which lesions appear and disappear. Assess for triggering factors. Assess for family history of angioedema; may indicate hereditary angioedema rather than allergic reaction.

Nursing Diagnoses
y

Disturbed Sensory Perception related to pruritus

Nursing Interventions Relieving pruritus

y y y y y y

Administer or teach self-administration of antihistamines, corticosteroids, and additional medications as prescribed. Encourage the proper use of topical and OTC agents, as directed. Advise patient to avoid exposure to heat, exercise, sunburn, and alcohol and to promptly control fever and anxietyfactors that may aggravate reactions caused by vasodilation. Warn patient to avoid identified triggers. Teach relaxation techniques and methods of distraction to enhance coping. Assess effectiveness of therapy.

Patient Education and Health Maintenance

y y

Warn the patient to monitor for symptoms of laryngeal edema and to seek medical intervention immediately if respiratory distress occurs. Instruct patients with laryngeal edema how to self-administer epinephrine.

Evaluation: Expected Outcomes Reports relief of pruritus with antihistamines and distraction methods FOOD ALLERGIES Food allergies result when the body's immune system overreacts to certain otherwise harmless substances. Food allergies occur in 4% to 6% of children and in 1% to 2% of adults, although the perceived prevalence is much higher because other existing adverse food reactions cause similar symptoms. Pathophysiology and Etiology
y y

Food hypersensitivity a true food allergy is an IgE-mediated response to a food allergen (protein). Food intolerance an abnormal physical response to a food or additive; is not immunologic. o Toxicity (poisoning)caused by toxins contained in foods, microorganisms, or parasites. o Pharmacologic (chemical)such as caffeine.

Idiosyncratic-etiology unknown. Common food allergens include cow's milk, eggs, shellfish, peanuts, tree nuts, soybean, and wheat.
o

Clinical Manifestations
y y y y

Respiratory-rhinoconjunctivitis, sneezing, laryngeal edema, wheezing. Cutaneous-urticaria, angioedema, atopic dermatitis. Gastroenteritis-lip swelling, palatal itching, nausea, abdominal cramping, diarrhea. Neurologic-migraine headaches in some patients.

Diagnostic Tests
y

y y

Skin testing. o Limit to those foods suspected of provoking symptoms based on history. o Only epicutaneous testing is done. o Intradermal testing has not been demonstrated to have a high degree of clinical correlation. RAST-positive result. Oral challenge. o The suspected food is given to the patient to identify the allergen by reproducing the symptoms caused by the initial reaction. o Open-may be used if the suspected food skin test result is negative; suspected food is openly administered and the patient is monitored for a reaction. o Single-blind-the suspected food is disguised in capsules, liquids, or other foods, and administered to the patient in increasing doses at intervals determined by history and may be interspersed with placebo. Some bias exists. o Double-blind placebo-controlled-the most definitive technique to confirm or refute histories of food allergies. The suspected food is administered in capsules or via some other vehicle that masks its identity, and is interspersed with placebo so neither the health care provider/nurse nor patient knows whether the suspected food or placebo is being ingested. Elimination diet. o To determine if the patient's symptoms will stop when certain foods are avoided. o Restrict one or two foods at a time if certain foods are suspected. o If no particular food is suspected, a highly restricted diet for 14 days is preferable.

Management
y y

Avoidance of specific foods is the only way of effectively preventing food allergy reactions. Medications: o Antihistamines-may modify IgE-mediated symptoms but will not eliminate them. o Corticosteroids-only used in the treatment of food allergy if associated with eosinophilic gastroenteritis or gastroenteropathy. o Epinephrine (Adrenalin)-if history of anaphylaxis, patient should carry it at all times (EpiPen).

Complications Anaphylaxis Nursing Assessment

y y y

Assist with assessment for offending foods; encourage the patient to keep a food and symptom diary. Auscultate lungs and document any wheezing. Assess compliance with prescribed diet and relief of symptoms.

Nursing Diagnoses
y

Imbalanced Nutrition: Less Than Body Requirements related to restrictive diet

Nursing Interventions Promoting Adequate Nutrition

y y y y y

Consult with dietitian to ensure a balanced diet that excludes identified allergens and incorporates patient's food preferences. Administer dietary supplements as needed. Discuss alternative food preparation techniques and methods of substitution (such as using extra baking powder in place of eggs). Administer and teach self-administration of medications, if necessary, to reduce abdominal cramping and diarrhea, which may deter food intake. Monitor weight.

Patient Education and Health Maintenance

y

Instruct the patient with history of anaphylactic reaction about self-injection technique for the administration of epinephrine.

Caution highly allergic patient about restaurant food; when eating out, patient should request ingredient information; brochures listing ingredients of various dishes are now available in many restaurants, including fast-food establishments. Explain hidden sources of foods to decrease the risk of unexpected exposure to an offending allergen. Some foods may contain allergens not as primary ingredients, but as fillers or additives. Likewise, a food that has been prepared or stored in the same container or cooled on the same surface as an allergen-containing food may become contaminated with a sufficient quantity of the allergen to cause a reaction. Encourage label reading. Advise patient that most young children and about one-third of older children and adults lose their food sensitivity after 1 to 2 years of avoidance. Compliance with elimination is the key. Sensitivity to shellfish and nuts is rarely lost, however.

Evaluation: Expected Outcomes Decreased frequency and severity of food allergy reactions by log; verbalizes acceptance of diet; weight stable LATEX SENSITIVITY Latex sensitivity is becoming a major health concern for health care workers, patients, and others at risk by occupation. Allergic reaction may be immediate or delayed. Latex is present in approximately 40,000 medical and other products, including household products and toys. The prevalence of latex sensitivity is estimated to be 1% in the general population, 20% in nurses, and more than 60% in children with spina bifida. Pathophysiology and Etiology
y y y

y y

Natural rubber latex, manufactured from the sap of rubber trees, is highly irritating and allergenic in some people. Increased use of latex, in the form of sterile and unsterile gloves, has made latex sensitivity a problem for many health care workers since the inception of Universal Precautions in the 1980s. Three types of reactions to latex may occur: o Irritant dermatitis-not an allergic reaction. o Type IV (cell-mediated, delayed) hypersensitivity-a localized contact allergic reaction. o Type I (IgE mediated, immediate) a systemic allergic reaction. No predictable pattern exists for the progression of reactions; anaphylaxis may occur at any time. More severe reaction occurs with latex contact with mucous membrane than with intact skin. Those at risk include children with spina bifida, health care workers, people with atopic allergies, people with a history of multiple surgeries, and workers in factories that produce latex products.

Clinical Manifestations
y y

Irritant dermatitis-may be caused by powder or chemical residue on gloveserythema and pruritus localized to area of contact; occurs immediately. Type IV (delayed) hypersensitivity contact allergic reaction erythema, pruritus, urticaria; possibly flushing, localized edema, rhinitis, coughing, and conjunctivitis. Symptoms occur 1 to 48 hours after contact with product.

Type I (immediate) hypersensitivity urticaria, angioedema, conjunctivitis, dyspnea, pharyngeal edema, arrhythmias, and anaphylaxis. Symptoms are immediate and may be moderate to lifethreatening in intensity.

Diagnostic Evaluation
y y y

y y

History of symptoms gives presumptive diagnosis, but confirmation is difficult because standardized tests are not yet widely available. A crude skin prick test uses a fragment of latex glove soaked in saline for 15 minutes as the solution. This is not standardized, but a positive test result is considered proof of latex sensitivity. A challenge test can be done by having the patient wear a latex glove or fingertip of a glove for 15 minutes; look for a reaction. Latex-free gloves can be used as a control. Severe reactions may occur with this test. Standardized skin testing will become more available pending Food and Drug Administration approval of standardized latex solution, but the threat of anaphylaxis will still exist. RAST testing is safe but expensive, and not as sensitive as skin testing.

Management
y y y y y y y y y

Avoidance is the key. For irritant reactions, changing brands of gloves may be sufficient, or changing to a powder-free glove. Decreasing length of exposure time or wearing cotton liners in gloves may help, but may not solve the problem. Use of latex-free gloves and products is usually necessary. Although more hospitals and medical offices are making latex-free products available, a job change may be necessary for some people. A latex-free environment is necessary for treatment. Topical corticosteroid creams for local reactions. Oral antihistamines may be used for mild to moderate reactions. Oral or parenteral corticosteroids, I.M. antihistamines, and I.M. or subcutaneous epinephrine are given for severe reactions. I.V. fluids, oxygen, and intubation may be needed for cardiovascular and pulmonary support with severe reactions.

Safety Measures to Prevent Latex Reactions If you do not work in a latex-free environment, remember:
y y y y y y y y y

Gloves are not a substitute for hand washing. If you must use lotion, use only water-based hand lotion. Use powder-free latex gloves to prevent dispersal and inhalation of aerosolized latex. Dispose of gloves properly; do not leave on counters. Wash and dry your hands well after glove removal. Avoid touching your eyes and face while wearing gloves. If symptoms develop, report them and document according to your facility's policy. Seek medical follow-up as indicated by symptoms. Maintain a safe environment for all patients and for all members of the health care team.

Nursing Assessment
y y y y y y

Assess patient for history of risk factors and pattern of suspected reactions. Assess skin for erythema, swelling, vesicles, and other lesions. Assess mucous membranes for conjunctivitis, rhinitis, and other lesions. For suspected systemic reactions, assess vital signs for hypotension, tachycardia, arrhythmia, respiratory distress. Assess respiratory status for stridor caused by laryngeal edema and breath sounds for wheezing. Assess for signs of internal edema with systemic reaction, such as nausea, vomiting, diarrhea.

Nursing Diagnoses
y

Deficient Knowledge related to sources of latex and how to avoid latex

Nursing Interventions and Patient Education

Increasing Knowledge about Latex Avoidance

y

Educate patients about the widespread use of latex and some possible alternatives (see Table 281). TABLE 28-1 Sources of Latex PRODUCT CONTAINING LATEX LATEX-FREE ALTERNATIVES Balloons Mylar balloons Chewing gum None Condoms, diaphragms Polyurethane condoms (male and female) Rubber bands String or clips Pacifiers Silicone products ToysKoosh, teething rings, dollsMost Fisher Price, Little Tykes, Discover, and Playschool toys Feminine hygiene products Kimberly-Clark products Adhesive bandages Cotton pads and plastic tape

y y y

Ensure that patients with history of Type I reaction have self-injectable epinephrine and antihistamines on hand at all times to use at first sign of a reaction. Encourage patients who have had moderate to severe reactions to wear a MedicAlert bracelet. Encourage patients to notify all their health care providers, labs, and clinics before they make a visit, to facilitate the use of latex-free products. These patients should be given the first appointment of the day and all supplies that contain latex should be removed from the room or covered with a cotton cloth. Only latex-free products should be used, and staff members should be careful to avoid wearing or removing latex gloves in the hall while the patient is in the office. Support the patient who has had a severe reaction in the workplace. Remind the patient that the Americans with Disabilities Act guarantees workers reasonable modifications to the workplace to accommodate a disability. However, the area of latex sensitivity as a disability is controversial.

BRONCHIAL ASTHMA Bronchial asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. This inflammation causes episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or early in the morning, and airway hyperreactivity to various stimuli. The episodes are usually associated with variable airflow obstruction that is usually reversible either spontaneously or with treatment. Few people with persistent asthma will develop irreversible fibrosis of the lining of the airways. Pathophysiology and Etiology The basic defect appears to be an abnormality in the host, which intermittently leads to an increased constriction of smooth muscle, hypersecretion of mucus in the bronchial tree, and mucosal edema. Neuromechanisms (Autonomic Nervous System)
y

Stimulation of the vagus nerve (which is responsible for bronchomotor tone) by viral respiratory infections, air pollutants, and other stimuli causes bronchoconstriction, increased secretion of mucus, and dilation of the pulmonary vessels. Beta-adrenergic receptor cells that line the airways are also responsible for bronchomotor tone. Abnormal functioning of these cells predisposes patients to bronchoconstriction.

Antigen-Antibody Reaction
y

y y y

Susceptible individuals form abnormally large amounts of IgE when exposed to certain allergens. Most children and half of adults with asthma are sensitized to at least one common inhaled allergen. IgE fixes itself to the mast cells of the bronchial mucosa. When the person is exposed to certain allergens, the resulting antigen combines with the cellbound IgE molecules, causing the mast cell to degranulate and release chemical mediators. These chemical mediators act on bronchial smooth muscle to cause bronchoconstriction, on dilated epithelium to reduce mucociliary clearance, on bronchial glands to cause mucus secretion, on blood vessels to cause vasodilation and increased permeability, and on leukocytes to cause a cellular infiltration and inflammation. Late-phase reactions (these occur 4 to 8 hours after the initial response) include the influx of eosinophils, neutrophils, lymphocytes, and monocytes.

Bronchial Inflammation

y y

Occurs in both the immediate- and late-phase reactions caused by antigen-antibody response. Factors other than allergens (such as noxious environmental stimuli) cause bronchial inflammation and hyperreactivity by mast cell activation.

Classification Extrinsic Asthma

y y

Hypersensitivity reaction to inhalant allergens (dust mites, animal dander, cockroaches, pollen, mold are the major ones). Mediated by immunoglobulin E (IgE mediated).

Intrinsic Asthma
y y y

No inciting allergen. Infection, typically viral. Environmental stimuli (such as air pollution).

Mixed Asthma Immediate type I reactivity appears to be combined with intrinsic factors. Aspirin-induced Asthma
y y

Induced by ingestion of aspirin and related compounds. Triad has been described as a combination of aspirin-induced asthma, nasal polyps, and sinusitis.

Exercise-induced Asthma Symptoms vary from slight chest tightness and cough to severe wheezing/cough and shortness of breath that usually occur after 5 to 20 minutes of sustained exercise. Occupational Asthma Due to inhalation of industrial fumes, dust, allergens, and gases. Classification by Persistence and Severity For treatment purposes, asthma is classified as mild intermittent, mild persistent, moderate persistent, and severe persistent based on symptoms Clinical Manifestations
y y y y

Episodes of coughing. Wheezing. Dyspnea. Feeling of chest tightness.

NURSING ALERT Do not be fooled by lack of wheezing on auscultation when the patient complains of severe shortness of breath. Airflow may be so restricted that wheezing ceases. Diagnostic Evaluation
y

y y

y y

Pulmonary function testing-> 12% increase over baseline in forced expiratory volume in first second of exhalation (FEV1) following inhalation of bronchodilator. Peak flow > 20% variability between AM and PM measurements. Laboratory-increased levels of IgE may be seen in atopic asthma. Bronchial methacholine challenge-demonstrates airway hyperreactivity by the inhalation of a cholinergic agent in serial concentrations delivered by nebulization; a positive response is indicated by a 20% decrease in FEV1 from baseline. Skin testing to identify causative allergens. Chest X-ray to exclude other lung diseases in new onset asthma in adult.

Management The goal is to allow the person with asthma to live a normal life. The treatment plan should be as simple as possible and individualized to the patient's lifestyle. It is important that the patient and his/her family be included in planning management of asthma. Usual Dosages for Long-term-control Medications MEDICATION DOSAGE FORM ADULT DOSE CHILD DOSE* Inhaled Corticosteroids (See Table 28-4.)

Systemic Corticosteroids Methylprednisolone 2-, 4-, 8-, 16-, 32mg tablets Prednisolone 5-mg tablets, 5 mg/5 cc, 15 mg/5cc Prednisone 1-, 2.5-, 5-, 10-, 20-, 50-mg tablets; 5 mg/cc, 5 mg/5 cc

7.5-60 mg daily in a single dose in a.m. or qod as needed for control Short-course burst to achieve control: 40-60 mg per day as single or two divided doses for 3-10 days

0.25-2 mg/kg daily in single dose in a.m. or qod as needed for control Short-course burst : 1-2 mg/kg/day, maximum 60 mg/day for 3-10 days

Long-acting Inhaled Beta2-agonists (Should not be used for symptom relief or for exacerbations. Use with inhaled corticosteroids.) Salmeterol MDI 21 mcg/puff 2 puffs q 12 hours 1-2 puffs q 12 hours DPI 50 1 blister q 12 hours 1 blister q 12 hours mcg/blister Formoterol DPI 12 1 capsule q 12 hours 1 capsule q 12 hours mcg/single-use capsule Combined Medication Fluticasone/SalmeterolDPI 100, 250, or 1 inhalation bid; dose depends on 1 inhalation bid; dose depends 500 mcg/50 mcg severity of asthma on severity of asthma Cromolyn and Nedocromil Cromolyn MDI 1 mg/puff 2-4 puffs tid-qid 1-2 puffs tid-qid Nebulizer 20 1 ampule tid-qid 1 ampule tid-qid mg/ampule Nedocromil MDI 1.75 mg/puff 2-4 puffs bid-qid 1-2 puffs bid-qid Leukotriene Modifiers Montelukast 4- to 5-mg 10 mg qhs y 4 mg qhs (2-5 years) chewable tablet y 5 mg qhs (6-14 years) y 10 mg qhs (>14 years) 10-mg tablet Zafirlukast 10- or 20-mg tablet 40 mg daily (20-mg tablet bid)
y y

20 mg daily (7-11 years) (10 mg tablet bid)

Zileuton

300- or 600-mg 2,400 mg daily (give tablets qid) tablet Methylxanthines (Serum monitoring is important [serum concentration of 5-15 mcg/mL at steady state].) Theophylline Liquids, Starting dose 10 mg/kg/day up to y Starting dose 10 sustained-release 300 mg max; usual max 800 mg/kg/day; usual max: y < age 1 year: 0.2 (age tablets, and mg/day in weeks) + 5 = capsules mg/kg/day y age 1 year: 16 mg/kg/day * Children age 12 DPI: dry powder inhaler; MDI: metered dose inhaler TABLE 28-4 Estimated Comparative Daily Dosages for Inhaled Corticosteroids MEDICATION AND FORM LOW DAILY DOSE MEDIUM DAILY DOSE HIGH DAILY DOSE Adult Child* Adult Child* Adult Child* Beclomethasone CFC 42 or 84 mcg/puff 168-504 84-336 504-840 mcg 336-672 mcg > 840 mcg > 672 mcg mcg mcg Beclomethasone HFA 40 to 80 mcg/puff 80-240 mcg 80-160 240-480 mcg 160-320 mcg > 480 mcg > 320 mcg mcg Budesonide DPI 200 mcg/inhalation 200-600 200-400 600-1,200 400-800 mcg > 1,200 > 800 mcg mcg mcg mcg mcg

Inhalation Suspension for Nebulization (child dose) Flunisolide 250 mcg/puff 500-1,000 mcg Fluticasone MDI: 44, 110, or 220 mcg/puff 88-264 mcg DPI: 50, 100, or 250 mcg/inhalation Triamcinolone Acetonide 100 mcg/puff 100-300 mcg 400-1,000 mcg

0.5 mg 500-750 mcg 88-176 mcg 100-200 mcg 400-800 mcg

1.0 mg

2.0 mg > 1,250 mcg

1,000-2,000 1,000-1,250 > 2,000 mcg mcg mcg

264-660 mcg 176-440 mcg > 660 mcg > 440 mcg 300-600 mcg 200-400 mcg > 600 mcg > 400 mcg 1,000-2,000 800-1,200 mcg mcg > 2,000 mcg > 1,200 mcg

* Children age 12 DPI: dry powder inhaler; MDI: metered dose inhaler Quick-relief Medications
y y y

Short-acting bronchodilators by inhalation. Beta-agonists, such as albuterol (Proventil, Ventolin), pirbuterol (Maxair), and levalbuterol (Xopenex). Anticholinergic agent ipratropium bromide (Atrovent). y Systemic corticosteroids (short course).

DRUG ALERT A short-acting bronchodilator, such as albuterol, is the drug of choice for acute asthma. Long-term Controllers
y y y y y y y y y

Inhaled corticosteroids, such as triamcinolone (Azmacort), beclomethasone (Vanceril, Beclovent, QVAR), fluticasone (Flovent), budesonide (Pulmicort), flunisolide (AeroBid). Long-acting inhaled beta-agonists include salmeterol (Serevent) and formoterol (Foradil). Combination inhalers, such as fluticasone and salmeterol (Advair). Leukotriene modifiers, such as montelukast (Singulair), zafirlukast (Accolate). Inhaled mast cell stabilizers include cromolyn sodium (Intal) and nedocromil (Tilade). Long-acting oral beta-agonists such as albuterol extended-release tablets [Volmax]). Oral corticosteroids (maintenance dose). Methylxanthines such as theophylline (Theo-24, Uniphyl, Theo-Dur). An IgE blocker (omalizumab [Xolair]) can be added to standard maintenance therapy to reduce exacerbations. o It is given by subcutaneous injection every 2 to 4 weeks. o The most common adverse reactions are injection site reactions and viral infection.

NURSING ALERT The most convenient and inexpensive method of aerosol delivery to patients is the metered-dose or dry powder inhaler; however, nebulization offers alternative delivery for those with unreliable inhaler technique. DRUG ALERT Beta-adrenergic blockers, such as propranolol (Inderal), have the potential to cause bronchoconstriction and should not be given to patients with asthma. Other Measures
y y y y y y y

Environmental control Immunotherapy Avoidance of foods that contain tartrazine (yellow dye no. 5) in aspirin-sensitive patients. Exercise: Regular aerobic exercise should be encouraged. Use of an inhaled beta-adrenergic agonist or cromolyn taken 15 to 20 minutes before exercise will decrease exercise-induced bronchospasm. Antibiotics are prescribed only during acute exacerbations if signs and symptoms of bacterial infection are present. Alternative and complementary therapies that include acupuncture, herbal preparations, yoga, and chiropractic treatment have been suggested for acute and chronic asthma control; however, none is a substitute for usual medical treatment. In fact, glucosamine and chondroitin have been

suspected of causing asthma exacerbation in some patients. Nursing Assessment

y y y y

y y

Review patient's record: ask about coughing, dyspnea, chest tightness, wheezing, exertional changes, and increased mucous production. Observe the patient and assess the rate, depth, and character of respirations, especially on expiration; observe for hyperinflation. Assess peak flow. Auscultate the chest for breath sounds or wheezing. Assess for triggers of asthma that include the following: o Allergens. o Respiratory infections. o Inhalation of irritating substances (dust, fumes, gases). o Environmental factors (weather, air pollution, and humidity). o Exercise, particularly in cold weather. o Aspirin and its derivatives. o Sulfite-containing agents used as food preservatives. o Emotional factors. After acute episode subsides, attempt to determine patient's degree of adherence with medications/management regimen. Observe inhalation technique.

Nursing Diagnoses
y y

Ineffective Breathing Pattern related to bronchospasm Anxiety related to fear of suffocating, difficulty in breathing, death

Nursing Interventions Attaining Relief of Dyspneic Breathing

y y y y y y y

Monitor vital signs, skin color, retraction, and degree of restlessness, which may indicate hypoxia. Provide medication and oxygen therapy as prescribed. Monitor airway functioning through peak flow meter or pulmonary function testing to assess effectiveness of treatment. Encourage intake of fluids to liquefy secretions. Instruct patient on positioning to facilitate breathingsitting upright (leaning forward on a table). Encourage patient to use adaptive breathing techniques (eg, pursued-lip breathing) to decrease the work of breathing. Use chest physiotherapy/postural drainage to mobilize secretions, if ordered.

Relieving Anxiety
y y y

Explain rationale for interventions to gain patient's cooperation. Provide care in prompt, confident manner. Help patient clarify sources of anxiety; suggest measures to reduce anxiety and to control breathing. Encourage active participation and support efforts to adhere to management plan.

Community and Home Care Considerations

y

y y

Initiate peak flow monitoring as ordered by health care provider. This may be done twice daily by the patient with persistent asthma. Provide written and verbal instruction and have the patient demonstrate the procedure. The patient can buy a peak flow meter from a pharmacy or from a medical supply company. Once optimal asthma control is obtained, daily peak flow measurements in the early morning and early afternoon should be used during a 2- to 3-week period to determine the patient's personal best. The personal best peak flow measurement will be used to monitor control and to guide selftherapy in an individualized action plan. Teach the patient to obtain peak flow measurement

Provide written and verbal instruction on an action plan for self-management of asthma exacerbation as outlined by the health care provider. National Asthma Education and Prevention Program Guidelines suggest the following: o For symptomatic worsening of asthma or asymptomatic decrease in peak flow measurement, use initial inhalation of a short-acting beta-adrenergic agonist by metereddose inhaler (MDI), two to four puffs for up to three treatments at 20-minute intervals, or a single nebulization treatment. o After initial treatment, recheck peak flow; if > 80% of personal best and no wheezing or shortness of breath, continue beta-adrenergic agonist every 3 to 4 hours for 24 to 48 hours. If on inhaled corticosteroids, double dose for 7 to 10 days. The patient should contact the health care provider for further instructions. o If peak flow is 50% to 80% of personal best, or if the patient has persistent wheezing and shortness of breath, an oral corticosteroid should be initiated and beta-adrenergic agonist should be continued. The patient should contact the health care provider the same day for further instructions. o If peak flow is < 50% of personal best or if the patient has significant wheezing and shortness of breath, an oral corticosteroid should be started, beta-adrenergic agonist should be repeated immediately, and the patient should proceed to the emergency department.

PATIENT EDUCATION GUIDELINES Obtaining a Peak Flow Measurement To obtain a peak flow measurement:
y y y y y y y

Place the indicator at the base of the numbered scale. Stand (preferably) or sit upright. Take a deep breath. Place the meter in mouth and close lips around mouthpiece, with tongue under the mouthpiece. Blow out as hard and as fast as possible. Coughing or spitting will result in a falsely elevated level. Note the measurement that the indicator is pointing to on the number scale. Repeat previous steps twice more and record the highest number.

PATIENT EDUCATION GUIDELINES How to Use an Inhaler and Spacer USING AN INHALER
y

y y y

y y y

Make sure that the medication canister is attached to the plastic inhaler and shake well or, if using a dry powder inhaler system (DPI), load the medication disk according to the manufacturer's instructions. If recommended, attach a spacer to your metered dose inhaler (MDI) (see using a spacer, at right). Breathe out through your mouth while sitting upright or standing. If not using a spacer, the open mouth method is preferred with an MDI: o Hold the inhaler up to 2 inches away from your open mouth. o While starting to inhale through your open mouth, use your index finger to press down firmly on the top of the canister o Continue to inhale for 3 to 5 seconds to obtain a full breath, then try to hold your breath for 5 to 10 seconds. o Exhale and breathe normally. If using the closed mouth method (recommended for DPI systems): o Place the mouthpiece of the inhaler in your mouth and close lips tightly around it. o While starting to inhale, use your index finger to press down firmly on the top of the canister. o Continue to inhale for 3 to 5 seconds to obtain a full breath, then hold your breath for 5 to 10 seconds. o Remove the inhaler from your mouth before you exhale and breath normally. If more than one inhalation is prescribed, wait at least 30 seconds before taking another inhalation, then repeat steps 1 to 5. Replace the mouthpiece cap after each use. Clean the inhaler thoroughly and frequently. Remove the metal canister and clean the inhaler and cap at least once per day by rinsing with warm, running water. Dry the inhaler and cap thoroughly with a gentle twisting motion.

Discard the canister after you have used the labeled number of inhalations. You should not use it beyond this indicated number because the correct dose amount can no longer be guaranteed. For dry powdered inhalers, use a forceful, rapid inhalation with closed mouth technique. See the instructions provided by the manufacturer of the device you use. USING A SPACER Unless you use your inhaler correctly, much of the medicine can end up on your tongue, on the back of your throat, or in the air. If you experience this problem, your health care provider may recommend using a spacer. Also called a holding chamber, a spacer is a device that attaches to a metered dose inhaler. It holds the medicine in its chamber long enough for you to inhale it in one or two slow, deep breaths, thereby enabling you to get your full dose of medicine. It also prevents you from coughing and may prevent a yeast infection in your mouth if you use a steroid inhaler. Several types of spacers are available; these devices may be purchased through your pharmacist.
y y y y y y

Attach the inhaler to the spacer or holding chamber as shown in the product instructions. Shake well. Press the canister on the inhaler, which will put one puff of medicine into the holding chamber. Place the mouthpiece of the spacer into your mouth and inhale slowly. Hold your breath a few seconds, then exhale. If your health care provider has prescribed two or more puffs, wait 1 minute and repeat steps 4 to 7.

Patient Education and Health Maintenance

y y

y y y y

Provide information on the nature of asthma and methods of treatment. Provide information regarding medications, including the difference between long-term controllers and quick relief medications and the proper use of inhalers and spacer devices; stress avoiding overuse of inhalers and nebulizers. Ensure that patient understands that long-acting bronchodilating inhalers such as salmeterol are not effective for asthma exacerbations. Demonstrate the use of MDIs and nebulization equipment. Help patient to identify what triggers asthma, warning signs of an impending attack, and strategies for preventing and treating an attack. Teach adaptive breathing techniques and breathing exercises such as pursed-lip breathing. Discuss environmental control. o Avoid people with respiratory infections. o Avoid substances and situations known to precipitate bronchospasm, such as allergens, irritants, strong odors, gases, fumes, and smoke. o Wear a mask if cold weather precipitates bronchospasm. o Stay inside when air pollution is high. Promote optimal health practices, including nutrition, rest, and exercise. o Encourage regular exercise to improve cardiorespiratory and musculoskeletal conditioning. o Drink liberal amounts of fluids to keep secretions thin. o Try to avoid upsetting situations. o Use relaxation techniques, biofeedback management. o Use community resources for smoking cessation classes, stress management, exercises for relaxation, asthma support groups, etc. Make sure that patient knows with whom to follow up and the frequency of follow-up. Discuss with patient how to overcome any barriers to follow-up, such as transportation, limited office or clinic hours, child care, and work requirements.

Evaluation: Expected Outcomes

y y

Symptoms (wheezing, coughing, chest tightness) reduced; peak flow improved Verbalizes relief of anxiety

STATUS ASTHMATICUS Status asthmaticus is a severe form of asthma in which the airway obstruction is unresponsive to usual drug therapy. Contributing Factors
y

Infection.

y y y y

Inhalation of air pollutants and allergens to which sensitized. Noncompliance in taking medications, including overuse of bronchodilators. Ingestion of aspirin or related drugs in aspirin-sensitive patient. Aspiration of gastric acid.

Clinical Manifestations
y y y y y y y

Tachypnea, labored respirations, with increased effort on exhalation. Suprasternal retractions, use of accessory muscles of respiration. Diminished breath sounds, decreased ability to speak in phrases/sentences. Anxiety, irritability, fatigue, headache, impaired mental functioning. Muscle twitching, somnolence, diaphoresis from continued carbon dioxide retention. Tachycardia, elevated blood pressure. Heart failure and death from suffocation.

Management and Nursing Interventions

y y

y y

y y y

Monitor respiratory rate and oxygen saturation continuously; frequently monitor arterial blood gas levels, blood pressure, electrocardiogram. Administer repeated aerosol treatments with beta2-agonist bronchodilators, such as albuterol (Ventolin) or levalbuterol (Xopenex); add anticholinergic ipratropium (Atrovent) as prescribed administer with caution until the metabolic and respiratory acidosis and hypoxemia have been corrected. Monitor I.V. therapy. o When I.V. fluids are administered, aminophylline (Aminophyllin) may be prescribed and administered slowly by constant infusion; the clinician must be constantly alert for signs of theophylline toxicity (tachycardia, nausea, vomiting, restlessness, dizziness). o Corticosteroids are given to treat inflammation of airways; because these act slowly, their beneficial effects may not be apparent for several hours. o Fluids are given to treat dehydration and loosen secretions. Provide continuous humidified oxygen via nasal cannula as prescribed. (Patients with associated chronic obstructive pulmonary disease or emphysema are at risk for depressed hypoxemic ventilatory drive, thus compounding respiratory insufficiency, so use oxygen cautiously.) Initiate mechanical ventilation, if necessary. Assist with mobilization of obstructing bronchial mucus. o Perform chest physiotherapy (chest wall percussion and vibration). o Administer expectorant and mucolytic drugs as prescribed. o Remove secretions by suctioning, or prepare for bronchoscopy if needed. Provide adequate hydration. Obtain portable chest X-ray and administer antibiotics as prescribed to treat any underlying respiratory infection. Alleviate the patient's anxiety and fear by acting calmly and by reassuring the patient during an attack. Stay with the patient until the attack subsides.

NURSING ALERT In status asthmaticus, the return to normal or increasing partial pressure of carbon dioxide does not necessarily mean that the patient with asthma is improving it may indicate a fatigue state that develops just before the patient slips into respiratory failure.