ASTHMA & IMMUNOLOGY FOCUS

June Zhang, MD treat and maybe one day cure the disease!

About the Author:

June Zhang, MD is a board-certified allergist and immunologist with the South Bay Allergy and Asthma Group. Certified by both the American Board of Pediatrics and the American Board of Allergy & Immunology, Dr. Zhang treats children and adults. She is passionate about treating food allergies, eczema, vocal cord dysfunction, asthma and chronic hives/swelling. Dr. Zhang graduated with honors with a Bachelor of Science in cell and molecular biology from the University of Washington in Seattle before earning her medical doctorate from the Medical College of Wisconsin in Milwaukee in 2003. She later completed her pediatrics residency at Children’s Hospital Oakland in California and then moved to Pennsylvania for an allergy and immunology fellowship at Children’s Hospital of Pittsburgh and University of Pittsburgh Medical Center. She speaks Mandarin fluently and is an active member of the California Medical Association, the San Mateo County Medical Association, South Bay American Medical Women’s Association and the American Academy of Allergy, Asthma & Immunology. She is also a fellow of the American College of Allergy, Asthma & Immunology.

Recognition

Anaphylaxis is an allergic medical emergency that requires prompt recognition and immediate, appropriate intervention. To help with recognition, recent guidelines state that anaphylaxis is highly likely when any of the following three criteria is fulfilled:

Sudden onset of illness with involvement of skin, mucosal tissue or both (e.g. hives, itching, flushing, swelling of lips, tongue or uvula)

AND

1. At least one of the following:

• sudden respiratory symptoms (shortness of breath, hypoxia, cough, wheeze, stridor),

• sudden reduced blood pressure * or end organ dysfunction (hypotonia, collapse, incontinence)

2. Two or more of the following after known exposure to a likely allergen or trigger:

• Sudden skin or mucosal involvement (hives, itching, flushing, swollen lips/tongue/uvula)

By John Kellogg, MD, MS

• Sudden respiratory involvement (wheezing, shortness of breath, cough, stridor, hypoxemia)

• Sudden reduced BP or end-organ dysfunction (hypotonia, collapse, incontinence)

• Sudden gastrointestinal symptoms (nausea, vomiting, diarrhea, abdominal cramping)

3. Reduced BP after exposure to a known allergen for that patient

*Reduced Blood Pressure is defined: Age

1 month to 1 year < 70 mm Hg

1 year to 10 years < 70 + (2 x age) mm Hg

11 years to 17 years < 90 mm Hg

Adult < 90 mm Hg or more than 30% drop in baseline

First Line Intervention:

The first line treatment of anaphylaxis is solely epinephrine and the administration of epinephrine should not be delayed.

Epinephrine is best administered IM in the anterolateral thigh using a 1:1,000 concentration (1 ml = 1 mg). IM poses much less risk for cardiac adverse events than IV and is just as rapid.

Dose:

Age/Weight Epinephrine Dose (1:1,000) IM

Adults

0.3 to 0.5 mg

Children > 25-30 kg 0.3 mg

Children < 25-30 kg 0.15 mg

If response is inadequate may repeat dose every 5 to 15 minutes. If response remains inadequate consider adding 1 mg of epinephrine to 1 liter normal saline and start an IV infusion at 2 ml/min and titrate the dose upward to 10 ml/min according to blood pressure, heart rate and oxygenation.

Second line interventions:

IV Fluids for circulatory symptoms and hypotension

Children <25-30 kg 10 ml/kg bolus, max 500 ml

Adults, children >25-30 kg 500 ml bolus

H1 Antihistamines for Urticaria, Flushing, Pruritus (ineffective for cardiovascular or respiratory symptoms)

Benadryl has no advantage over second generation antihistamines when given PO.

Onset of action is 30 minutes with peak plasma levels in 60120 minutes. Benadryl may be given IM or IV. Cetirizine 10 mg IV is available as an alternative to Benadryl 50 mg IV with less side effects.

H2 Antihistamines for GI symptoms (ineffective for cutaneous symptoms)

Steroids for prevention of biphasic anaphylaxis (no role in acute reactions because onset of action is 4-6 hours)

Epinephrine nebs for laryngeal symptoms or stridor (1 mg epinephrine in 4 ml normal saline via nebulizer)

Albuterol nebs for bronchospasm, wheezing, chest tightness (5 mg albuterol in adults/children, 2.5 mg in preschool children via nebulizer) (alternative albuterol HFA + spacer 6 puffs adult/ Child, 4 puffs preschool child)

Oxygen for respiratory symptoms, hypoxia. (6 L/min will drive a nebulizer set)

Observation:

Until stable, at least one hour after onset, and at least 30 minutes after the last epinephrine. Consider extended observation for at least six hours if there are risk factors for a biphasic anaphylactic reaction such as severe initial reaction and >1 dose of epinephrine needed.

About the Author:

John Kellogg, MD, MS is an Allergy, Asthma, & Immunology Physician with the South Bay Allergy and Asthma Group, Inc. Born in San Francisco, Dr. Kellogg spent some time in the Navy after graduation from the U.S. Naval Academy as a Naval Flight Officer (NFO). He subsequently attended Stanford University to get a Masters in Biological Sciences and Tulane University Medical School to complete his MD. After residency in Internal Medicine at UCSF, he served as a staff physician at the Naval Hospital in Lemoore, CA. During his tour of duty he was appointed President of the Medical Staff of the hospital. He then went on to an allergy fellowship in Texas with the San Antonio Uniformed Services Health Education Center. Finishing 24 years of combined Navy service as the staff allergist at Naval Medical Center Portsmouth VA, he joined the South Bay Allergy and Asthma Group in 2005. Dr. Kellogg’s special interests include chronic sinusitis, immune deficiencies, contact dermatitis as well as asthma and allergic rhinitis.

Up to 40% of patients report that at some time in their life, they have had an adverse reaction to a medication. Many of these are non-immune mediated reactions, however drug allergies affect a significant portion of the population.

Approximately 10% of patients report a history of reacting to a penicillin class antibiotic; however, when evaluated for penicillin allergy, up to 90% of these individuals are able to tolerate penicillins and therefore are designated as being penicillin-allergic unnecessarily. This emphasizes the importance of correct diagnostic testing for patients with a history of penicillin reactions.

Though penicillin allergy is certainly the most common drug allergy that we see, we are also able to evaluate possible reactions to other antibiotics, anti-hypertensives, local anesthetics, and pain medications. Many of these medications do not have validated allergy testing available, however we are able to discuss and determine whether a drug challenge would be appropriate. At South Bay Allergy & Asthma Group, we have extensive experience in the diagnosis and management of drug allergies. If you have a patient with a history of drug allergy, let us know—we can help!

About the Author:

Katharine Nelson, MD is a board-certified allergist and immunologist with the South Bay Allergy and Asthma Group and specializes in the comprehensive diagnosis and treatment of aller-

By Katharine Nelson, MD

gies and asthma in children and adults. She is certified by both the American Board of Pediatrics and the American Board of Allergy & Immunology. Dr. Nelson graduated with a Bachelor of Science in Medical Microbiology and Immunology, with honors, from the University of Wisconsin in Madison, before completing her Doctor of Medicine at the University of Wisconsin Medical School. She then completed her Pediatrics residency at UPMC Children’s Hospital of Pittsburgh in Pennsylvania, serving as chief resident. Dr. Nelson came to the Bay Area in 2009 to complete her fellowship training in Allergy and Immunology at Stanford University. Her special interests and areas of expertise include food allergy, urticaria (hives), angioedema, allergic rhinitis, asthma, and pediatric and adult immune deficiency. Outside of her clinical work, Dr. Nelson is on the board of South Bay American Medical Women’s Association and was an adjunct clinical faculty member at Stanford University School of Medicine. She is also an active member of the American Academy of Allergy, Asthma & Immunology, the American Academy of Pediatrics, Western Society of Allergy, Asthma and Immunology and the American College of Allergy, Asthma & Immunology.

MD