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Anaphylaxis Johannes Ring Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein Technische Universität München Munich, Bavaria, Germany.

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Presentation on theme: "Anaphylaxis Johannes Ring Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein Technische Universität München Munich, Bavaria, Germany."— Presentation transcript:

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 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: Anaphylaxis is an (acute) severe, life-threatening generalized or systemic hypersensitivity reaction (regardless of mechanism)

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 SkinGastro- intestinal RespiratoryCardio-vascular I Itch Flush Urticaria Angioedema --- II (not obligatory) Nausea Cramps Rhinorrhoea Hoarseness Dyspnoea Tachycardia (>20/min) RR changes (>20mmHg syst) Arrhythmia III (not obligatory) Vomitus Defecation Laryngeal edema Bronchospasm Cyanosis Shock IV (not obligatory) Respiratory arrest Cardiac arrest

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

11 Triggers of Anaphylaxis Modif. After Hompes S et al 2009 TriggerAdultsChildren Foods1654 Insects5516 Drugs218

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

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

14 Summation anaphylaxis Nahrungsmittel Infekte Streß Klima Sport Arzneimittel Alkohol

15 Guidelines in Anaphylaxis 1994Konsensuskonferenz DGAI Tryba et alAllergo-J 2005Update parameter AAAAI Lieberman et al JACI 20062nd symposium NIH / FAN Sampson et al JACI 2007Leitlinie Akutmaßnahmen bei Anaphylaxie Ring et al (DGAKI)Allergo-J 2007Anaphylaxis in childhood (EAACI) Muraro et al Allergy 2008Epinephrine – drug of choice (WAO) Kemp et al WAO Journal 2011Development 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 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 Symptoms of anaphylaxis 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 General measures Adrenaline Volume Basics of Treatment of Anaphylaxis 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 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

26 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

27 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 Anaphylaxis School: Contents 1st Day Day 1, Unit 1 b

28 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 Anaphylaxis School: Contents 2nd Day

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/childrens nurse: optional

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

31 Prevention avoid triggers know alternatives immunotherapy for Insect venom allergy take emergency drugs always along train application of emergency drugs inform social environment 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 patients life

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

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