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

3. Anaphylaxis: definition by the World Allergy Organization
„Anaphylaxis is an (acute) severe, life-threatening generalized or systemic hypersensitivity reaction“ (regardless of mechanism)
there is no universal agreement on its definition or criteria for diagnosis. Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. In MC it is unknown what may cause death.
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

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

5. Anaphylactic Reaction after Infusion of Dextran 60

6. Day 1, Unit 2a

7. Severity grading of anaphylactic reactions according to Ring and Meßmer (Lancet, 1977)
Grade
Symptoms observed
Skin
Gastro-intestinal
Respiratory
Cardio-vascular I
Itch
Flush
Urticaria
Angioedema - II „
(not obligatory)
Nausea
Cramps
Rhinorrhoea
Hoarseness
Dyspnoea
Tachycardia
(>20/min)
RR changes
(>20mmHg syst)
Arrhythmia
III
Vomitus
Defecation
Laryngeal
edema
Bronchospasm
Cyanosis
Shock IV
Respiratory arrest
Cardiac arrest

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

9. 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)

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

11. Triggers of Anaphylaxis
Modif. After Hompes S et al 2009
Trigger
Adults
Children
Foods 16 54
Insects 55
Drugs 21 8

12. Elicitors or letal anaphylaxis
Drugs
Insect venoms
Auch idiopathische Ax
Foods
Pumphrey. Clin Exp Allergy 2000; 30:1144

13. 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
Kaum eine andere Gruppe von Erkrankungen hat in den
letzten Jahrzehnten eine ähnliche Zunahme erlebt wie
die Allergien. ¼ aller Menschen sind bereits davon betroffen

14. Summation anaphylaxis
Sport
Nahrungsmittel
Klima
NM-Allergie
Arzneimittel
Streß
Infekte
Alkohol

15. Guidelines in Anaphylaxis
1994 Konsensuskonferenz DGAI Tryba et al Allergo-J
2005 Update parameter AAAAI Lieberman et al JACI
nd 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

16. 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)

17. 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

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

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

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

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

22. 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

23. 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

24. 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

25. TU =teaching unit á 45 minutes
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

26. 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

27. 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

28. 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

29. 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

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

31. inform social environment
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

32. 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

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