Transcript ring-anaphylaxis-WAC-Cancun-2011

Anaphylaxis
Johannes Ring
Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein
Technische Universität München
Munich, Bavaria, Germany
GA2LEN Center of Excellence EU frame program
Christine Kühne Center for Allergy Research and Education (CK-CARE)
XXII World Allergy Congress WAC
4 – 4 december 2011, Cancun Mexico
Anaphylaxis: definition by the World Allergy
Organization
„Anaphylaxis is an (acute) severe, life-threatening
generalized or systemic hypersensitivity reaction“
(regardless of mechanism)
Johansson SGO et al. Revised nomenclature for allergy for global use: Report of
the Nomenclature Review Committee of the World Allergy Organization,
J Allergy Clin Immunol. 2004;113:832-6.
Increase in Incidence of Anaphylaxis
Liew WK. Anaphylaxis fatalities and admissions in Australia. J Allergy Clin Immunol 2009;123:434-42
Anaphylactic Reaction after Infusion of Dextran 60
Day 1, Unit 2a
Severity grading of anaphylactic reactions according to
Ring and Meßmer (Lancet, 1977)
Symptoms observed
Grade
Skin
I
Itch
Flush
Urticaria
Angioedema
II
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(not obligatory)
III
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(not obligatory)
IV
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(not obligatory)
Gastrointestinal
Respiratory
Cardio-vascular
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Nausea
Cramps
Vomitus
Defecation
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Rhinorrhoea
Hoarseness
Dyspnoea
Laryngeal
edema
Bronchospasm
Cyanosis
Respiratory
arrest
Tachycardia
(>20/min)
RR changes
(>20mmHg syst)
Arrhythmia
Shock
Cardiac arrest
Activators
Allergen
Mast Cells
Mediators
Histamine
Auto-Ab (IgE,FcRI)
Anaphylatoxin
Tryptase
Basic agents
(Neuropeptides,
48/80,MBP)
Adenosin
Chemokines
Proteoglykanes
Proteases
Other Enzymes
Cytokines
Lipid mediators
Stem cell factor
(c-kit-Ligand)
Microbial Peptides
I. Weichenmeier, H. Behrendt
33 jährige Patientin mit Mastozytose (ISM) seit 4 Jahren
Bronchialasthma
Keine frühere Allergie oder Anaphylaxie
Basale Tryptase 57µg/l
Patientin wurde von Wespe in den Nacken gestochen
Patientin hatte kein Notfall-Set dabei
Tachykardie, Kollaps,
Bewußtseinsverlust innerhalb weniger Minuten
Reanimation anfangs erfolgreich, aber
später auf Intensivstation Tod durch hypoxischen Hirnschaden
Frage einer evtl. „prophylaktischen“ ASIT (Immuntherapie)
Mechanisms of anaphylaxis
nettle rash
dyspnoea
mast cell
diarrhea, vomiting
shock
mediator substances
eg histamine
Day 1, Unit 2a
Triggers of Anaphylaxis
Trigger
Adults
Children
Foods
16
54
Insects
55
16
Drugs
21
8
Modif. After Hompes S et al 2009
Elicitors or letal anaphylaxis
Insect venoms
Drugs
Foods
Pumphrey. Clin Exp Allergy 2000; 30:1144
Circumstances of fatal food anaphylaxis
• Most of patients are aware of food allergy
• Mostly young asthmatics
• Several mild reactions in previous history
• Difficulties in complete avoidance
• Reactions occur mostly not at home, but in school,
kindergarden , bars, restaurants, „Take-Away“,
Caterer
Summation anaphylaxis
Sport
Nahrungsmittel
Klima
Arzneimittel
Streß
Infekte
Alkohol
Guidelines in Anaphylaxis
• 1994
• 2005
• 2006
• 2007
• 2007
• 2008
• 2011
Konsensuskonferenz DGAI
Tryba et al
Allergo-J
Update parameter AAAAI
Lieberman et al
JACI
2nd symposium NIH / FAN
Sampson et al
JACI
Leitlinie Akutmaßnahmen bei Anaphylaxie
Ring et al (DGAKI)
Allergo-J
Anaphylaxis in childhood (EAACI)
Muraro et al
Allergy
Epinephrine – drug of choice (WAO)
Kemp et al
WAO Journal
Development of Global Guidelines (WAO)
Simons et al
JACI
Development of „Anaphylaxis School“
by working group AGATE (AG
Anaphylaxis Training and Education)
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Johannes Ring, Knut Brockow,
Claudia Kugler, Martine Grosber
Verena Thiebes (München TUM)
Kirsten Beyer, Norbert Gebert (Berlin)
Margitta Worm (Berlin)
Tilo Biedermann, A Fischer (Tübingen)
Alexander Dorsch (Hohenkammer)
Ricarda Eben, B Przybilla (München
LMU)
Frank Friedrichs (Aachen)
Uwe Gieler, S Schallmayer (Gießen)
Thilo Jakob (Freiburg)
Lars Lange (Bonn)
Oliver Pfaar, Ludger Klimek (Wiesbaden)
Imke Reese (München)
Ernst Rietschel (Köln)
Sabine Schnadt (daab)
Rüdiger Szczepanski (Osnabrück)
Symptoms of anaphylaxis
Skin:
Itch, reddening, swelling,
nettle rash
Gastrointestinal tract:
Itchy palate, nausea, vomiting,
abdominal cramps, diarrhea
Respiratory tract:
Cold, narrow throat,
stridor, cough, dyspnoea
Cardiovascular:
Vertigo, disorientation, tachycardia
hypotension, collapse,
unconsciousness shock
Day 1, Unit 2a
AGATE
Interdisciplinary Group:
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Dermatologist
Emergency Physician
ENT
Pneumologist
Nutritionist
Pediatrician
Psychologist
Patient organisation
Struktured educational programs („Schools“)
in allergy
• Asthma
Arbeitsgemeinschaft Asthma-Schulung (AGAS)
• Neurodermitis
Arbeitsgemeinschaft Neurodermitis-Schulung
(AGNES)
• Anaphylaxie
Arbeitsgemeinschaft Anaphylaxie – Training und
Edukation (AGATE)
Basics of Treatment of Anaphylaxis
General measures
Volume
Adrenaline
Antihistamine
Glucocorticoids
„Emergency Set“ for self-medication
• Adrenaline, Antihistamine, Cortisone
• Application galenics for easy swallowing
• Adrenaline as Autoinjector
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Objectives of AGATE
• Basic knowledge anaphylaxis (symptoms,
medication)
• Coping with anaphylactic reactions
• Practical training in use of self medication
• Avoiding triggers
• Coping with fear
• Exchange of experiences with other patients
Who is educated?
• Patients and relatives
• Patients to whom an epinephrine
autoinjector was prescribed (anaphylaxis,
adults with mastocytosis)
• Train the Trainer Seminars: Physicians
(Allergists), Psychologists, Nutritionists
Structure of Programmme
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Outpatient education
2 Meetings with 4 units of 45 minutes
Interdisciplinary approach
Standardised programme with manual
Groups of 6 adults or 12 parents of 6
children
Qualification for „Anaphylaxis Trainer“
according to the AGATE curriculum: Contents
• Opportunities and limits of educational programs (1 TU)
• Basics of organization and management of patient
education schools (3 TU)
• Psychosocial aspects (6 TU)
• Pedagogic basics (8 TU)
• Medical aspects of anaphylaxis (10 TU)
TU =teaching unit á 45 minutes
Qualification for „Anaphylaxis Trainer“
according to the AGATE curriculum:
Pedagogic content
• Methodic/didactic opportunities for all age
groups
• Adequate didactic tools and gadgets for working
with children, parents and adults or
kindergarden personel
• Group dynamics
• Group structuring, processes, intervention
methods
• Relaxation and body perception
• Role performance games illustrating initiation
and solution of problems under everyday
conditions
Anaphylaxis School: Contents 1st Day
• Basics of anaphylaxis
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Symptoms, early warning signs
Triggers
Diagnosis and differential diagnoses
Individual risk and influencing factors
• Survey of treatment options
– Trigger avoidance
– Allergen-specific immunotherapy (ASIT)
– Outlook to future approaches
• Practical management in case of emergency
– Emergency set: medications
– Application of emergency medication
– Adrenaline autoinjector training
Day 1, Unit 1 b
Anaphylaxis School: Contents 2nd Day
• What to do in case of emergency? (repetition)
– Anaphylaxis
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Recognition
Remembering
Counteracting
Taking serious
• Elicitor-specific modules for:
– Foods
– Insect venoms
- Drugs
- Latex
• Everyday survival strategies
• Anaphylaxis and social environment
Day 2, Unit 1b
Qualification for „Anaphylaxis Trainer“
according to the AGATE curriculum
• Medical: Allergist or equivalent experience
• Psychological: Psychology, Psychosomatic medicine,
Psychotherapy, pedagogics plus > 1 year experience in
behavioural therapy with chronic diseases
• Nutrition: ecotrophology, dietary assistance with special
experience in food allergy (membership in WG)
• Nurse/children‘s nurse: optional
Qualification for „Anaphylaxis Trainer“
according to the AGATE curriculum: Program
• Hospitation (observer) in anaphylaxis school
• Train-the-Trainer seminar
• Supervision
• Certificate
avoid triggers
take emergency
drugs always along
train application of
emergency drugs
know
alternatives
Prevention
inform social
environment
individual
emergency plan
immunotherapy for
Insect venom allergy
know
symptoms
remember
Day 1, Unit 3
Conclusions
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Anaphylaxis is not rare
Main elicitors are drugs, insects and foods
Adrenaline is the main drug in acute treatment
It is important to find causal elicitor by allergy
diagnostics
If possible, allergen-specific immunotherapy
Research regarding „summation“ factors is
necessary
Strict avoidance of elicitor is best prevention
The „anaphylaxis school“ program is helpful in
acute management and avoidance of elicitors
thus facilitating patient‘s life
Thanks to:
K. Brockow
C. Kugler
U. Darsow
M. Grosber
V. Thiebes