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Anaphylaxis Johannes Ring

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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


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

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