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Anaphylaxis

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)

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Anaphylaxis

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  1. 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

  2. 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.

  3. Increase in Incidence of Anaphylaxis Liew WK. Anaphylaxis fatalities and admissions in Australia. J Allergy Clin Immunol 2009;123:434-42

  4. Anaphylactic Reaction after Infusion of Dextran 60

  5. Day 1, Unit 2a

  6. Severity grading of anaphylactic reactions according to Ring and Meßmer (Lancet, 1977)

  7. Mast Cells Activators Allergen Auto-Ab (IgE,FcRI) Anaphylatoxin Tryptase Basic agents (Neuropeptides, 48/80,MBP) Adenosin Chemokines Stem cell factor (c-kit-Ligand) Microbial Peptides Mediators Histamine Proteoglykanes Proteases Other Enzymes Cytokines Lipid mediators I. Weichenmeier, H. Behrendt

  8. 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)

  9. Mechanisms of anaphylaxis nettle rash dyspnoea diarrhea, vomiting mast cell shock mediator substances eg histamine Day 1, Unit 2a

  10. Triggers of Anaphylaxis Modif. After Hompes S et al 2009

  11. Elicitors or letal anaphylaxis Drugs Insect venoms Foods Pumphrey. Clin Exp Allergy 2000; 30:1144

  12. 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

  13. Summation anaphylaxis Sport Nahrungsmittel Klima Arzneimittel Streß Infekte Alkohol

  14. 1994 Konsensuskonferenz DGAI Tryba et al Allergo-J 2005 Update parameter AAAAI Lieberman et al JACI 2006 2nd symposium NIH / FAN Sampson et al JACI 2007 Leitlinie Akutmaßnahmen bei Anaphylaxie Ring et al (DGAKI) Allergo-J 2007 Anaphylaxis in childhood (EAACI) Muraro et al Allergy 2008 Epinephrine – drug of choice (WAO) Kemp et al WAO Journal 2011 Development of Global Guidelines (WAO) Simons et al JACI Guidelines in Anaphylaxis

  15. Development of „Anaphylaxis School“ by working group AGATE (AG Anaphylaxis Training and Education) • 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)

  16. 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

  17. AGATE Interdisciplinary Group: Dermatologist Emergency Physician ENT Pneumologist Nutritionist Pediatrician Psychologist Patient organisation

  18. Asthma Arbeitsgemeinschaft Asthma-Schulung (AGAS) Neurodermitis Arbeitsgemeinschaft Neurodermitis-Schulung (AGNES) Anaphylaxie Arbeitsgemeinschaft Anaphylaxie – Training und Edukation (AGATE) Struktured educational programs („Schools“) in allergy

  19. Basics of Treatment of Anaphylaxis General measures Volume Adrenaline Antihistamine Glucocorticoids

  20. Adrenaline, Antihistamine, Cortisone Application galenics for easy swallowing Adrenaline as Autoinjector „Emergency Set“ for self-medication + +

  21. 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

  22. 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

  23. Structure of Programmme 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

  24. 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) Qualification for „Anaphylaxis Trainer“according to the AGATE curriculum: Contents TU =teaching unit á 45 minutes

  25. 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 Qualification for „Anaphylaxis Trainer“according to the AGATE curriculum: Pedagogic content

  26. Anaphylaxis School: Contents 1st Day • Basics of anaphylaxis • 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

  27. Anaphylaxis School: Contents 2nd Day • What to do in case of emergency? (repetition) • Anaphylaxis • Recognition • Remembering • Counteracting • Taking serious • Elicitor-specific modules for: • Foods - Drugs • Insect venoms - Latex • Everyday survival strategies • Anaphylaxis and social environment Day 2, Unit 1b

  28. 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

  29. Hospitation (observer) in anaphylaxis school Train-the-Trainer seminar Supervision Certificate Qualification for „Anaphylaxis Trainer“according to the AGATE curriculum: Program

  30. take emergency drugs always along avoid triggers train application of emergency drugs know alternatives Prevention inform social environment immunotherapy for Insect venom allergy individual emergency plan know symptoms remember Day 1, Unit 3

  31. Conclusions 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

  32. Thanks to: K. Brockow C. Kugler U. Darsow M. Grosber V. Thiebes

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