Leitlinie zu Akuttherapie und Management der Anaphylaxie - Update 2021: S2k-Leitlinie der Deutschen Gesellschaft für Allergologie und klinische Immunologie (DGAKI), des Ärzteverbands Deutscher Allergologen (AeDA), der Gesellschaft für Pädiatrische Allergologie und Umweltmedizin (GPA), der Deutschen Akademie für Allergologie und Umweltmedizin (DAAU), des Berufsverbands der Kinder- und Jugendärzte (BVKJ), der Gesellschaft für Neonatologie und Pädiatrische Intensivmedizin (GNPI), der Deutschen Dermatologischen Gesellschaft (DDG), der Österreichischen Gesellschaft für Allergologie und Immunologie (ÖGAI), der Schweizerischen Gesellschaft für Allergologie und Immunologie (SGAI), der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), der Deutschen Gesellschaft für Pharmakologie (DGP), der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), der Patientenorganisation Deutscher Allergie- und Asthmabund (DAAB) und der Arbeitsgemeinschaft Anaphylaxie - Training und Edukation (AGATE)

[Prehospital care of anaphylactic reactions by the air rescue and ground-based emergency services Dresden : An analysis of treatment and outcome]

BACKGROUND

Anaphylaxis can lead to a life-threatening situation. Therefore, rapid diagnosis and emergency treatment is indicated. Immediate treatment with intramuscular adrenaline (or intravascularly with sufficient medical expertise) in anaphylaxis with cardiovascular and/or respiratory symptoms is recommended by various guidelines. Previous studies have shown that anaphylaxis is often not treated according to guidelines and that adrenaline in particular is rarely administered.

OBJECTIVE

The aim of the study was to investigate the data on emergency treatment and outcomes of patients with anaphylaxis by the air rescue and ground-based emergency services Dresden. Moreover, the results of the air- and ground-based services were compared. The focus was on administration of adrenaline and outcomes.

MATERIALS AND METHODS

Data from the ground-based emergency service Dresden (from 2012 to 2016) and the air rescue service Dresden (from 2008 to 2015) related to anaphylactic reactions were analyzed retrospectively. The severity of the anaphylaxis, the emergency medication administered, further monitoring, and outcomes were analyzed.

RESULTS

Data from 152 adults/29 children were analyzed for air rescue and 1131 adults/223 children for the ground-based emergency service. Adults with grade II-IV anaphylaxis received adrenaline in 19% (air rescue) and 7% (ground rescue) of cases. Children with grade II-IV anaphylaxis received adrenaline in 7% (air rescue) and 8% (ground rescue) of cases. Immediate drug therapy led to an improvement in general condition in 96-98% (air rescue) and 72-77% (ground-based emergency service) of cases. A significant correlation was found between the administration of adrenaline and the improvement in outcome in the ground-based emergency cohort.

CONCLUSION

Guideline-compliant first-line therapy with adrenaline was not performed in the majority of the cases analyzed in this study. The significant effect of adrenaline on outcome demonstrated in this study emphases the need to improve the emergency treatment of anaphylactic reactions.

[Breathing disorders in children]

Breathing disorders in children are one of the most common challenges for both parents and physicians. The first step should always consist of the initial clinical assessment concerning the potentially critically ill patient. Using the pediatric assessment triangle (PAT), the rapid evaluation of airway and breathing is crucial. Although the etiology of pediatric breathing disorders is manifold, we would like to focus on common diagnoses. Based on the three leading symptoms stridor, wheeze, and tachypnea, the most important diseases of pediatric patients are presented and initial treatment steps are discussed. We target crucial, life-saving, basic medical procedures that should be mastered and performed in and also outside of specialized centers or pediatric units.

Varying Approaches to Management of IgE-Mediated Food Allergy in Children Around the World

Food allergy is a chronic disease that affects individuals of all ages and is a significant public health problem globally. This narrative overview examines clinical management strategies for IgE-mediated food allergy in children around the world to understand variations in practice. Information was drawn from clinical practice guidelines, recent research, the websites of professional and governmental bodies with expertise in food allergy, and clinical experts from a broad cross-section of geographical regions. The structure and delivery of clinical services, allergen avoidance and food labeling, and resources to support the management of allergic reactions in the community are discussed in detail. The adoption of emerging food immunotherapies is also explored. Wide variations in clinical management of food allergy were apparent across the different countries. Common themes were continuing issues with access to specialist care and recognition of the need to balance risk reduction with dietary and social restrictions to avoid unnecessary detrimental impacts on the quality of life of food allergy sufferers. Findings highlight the need for standardized presentation of practice and priorities, and may assist clinicians and researchers when engaging with government and funding agencies to address gaps.

Inhibition of Complex I of the Respiratory Chain, but Not Complex III, Attenuates Degranulation and Cytokine Secretion in Human Skin Mast Cells

The mechanisms of mast cell (MC) degranulation and MC-driven skin symptoms are well-described. In contrast, data about the role of mitochondrial respiration for immune functions of human skin MCs are lacking. Oxygen consumption rate (OCR) in primary human skin MCs during IgE-mediated activation in the absence of glucose was examined using a metabolic flux analyzer. Effects of the inhibition of mitochondrial complex I (by rotenone A) and III (by myxothiazol) on degranulation and cytokine secretion (IL-4, IL-5, IL-6, IL-13, TNF-α, and GM-CSF) were explored by the β-hexosaminidase release assay and multiplex ELISA. IgE-mediated activation rapidly increased the mitochondrial OCR and extracellular acidification; the contribution of non-mitochondrial oxygen consumption remained unchanged at lower levels. Both myxothiazol and rotenone A reduced OCR, the mitochondrial parameters, and extracellular acidification; however, myxothiazol did not affect degranulation and cytokine secretion. In contrast, degranulation and the secretion of IL-6, IL-13, TNF-α, and GM-CSF were reduced by rotenone A, whereas the secretion of IL-4 and IL-5 was not significantly affected. The inhibitors did not affect cell viability. Our results highlight the important role played by mitochondrial respiration in primary human skin MCs and allow for a conclusion on a hierarchy of their effector functions. Drugs targeting specific pathways in mitochondria may provide future options to control MC-driven skin symptoms.

[Management of immunoglobulin-E-mediated food allergies : What remains and what is new?]

In this article, the current recommendations from the recently updated S2k guideline on the management of immunoglobulin E (IgE)-mediated food allergy are presented. These include information on the frequency of food allergies, food allergy prevention, clinical pictures and differential diagnostics, as well as food allergy diagnostics including in vivo and in vitro diagnostics, and finally aspects of the course and therapy of food allergy.

[Management of severe nut allergy in adults]

We present a case of walnut allergy in a 24-year-old man. The allergy work up revealed sensitization to walnut including a positive skin prick test and a high value of walnut-specific IgEs. The patient showed an anaphylactic reaction during the double blind placebo-controlled food challenge, to a cumulative dose of 3.723 g of walnut protein. The oral food challenge resulted in counseling regarding strict walnut avoidance and optimization of the emergency management. At follow-up the patient reported that having adhered to the recommended dietary measures resulted in no further allergic reactions.

[Diagnostic and therapeutic approach to anaphylaxis in childhood and adolescence]

Anaphylaxis is a suddenly occurring potentially life-threatening systemic allergic reaction. In childhood, food allergens play a major role but insect stings and drugs are also potential triggers. The symptoms appear in minutes up to few hours on the skin, airways, gastrointestinal tract and/or the cardiovascular system. Intramuscular adrenaline is the drug of first choice due to its rapid effectiveness and its low side effect potential. A detailed patient history and the determination of potential IgE antibodies must be carried out to identify the triggers. The register for anaphylaxis has improved knowledge on epidemiology. An education in anaphylaxis is useful for every patient as well as parents and caregivers. Allergen-specific immunotherapy is currently the only causal treatment option; however, at the present time it is only available for insect bites and peanut allergy.

Emergency Treatment of Anaphylactic Reactions in Air Rescue Missions: An Eight-Year Analysis of a German Rescue Helicopter Base

INTRODUCTION

Anaphylactic reactions can lead to a life-threatening situation. In the event of anaphylaxis, rapid and targeted emergency treatment is indicated.

STUDY OBJECTIVE

The study sought to determine the emergency therapy administered for anaphylaxis in children and adults. Focus was placed on therapy with adrenaline. In addition, the study aimed to investigate demographic data, triggers, and hospitalization rates of the different severities of anaphylaxis.

METHODS

A retrospective analysis of anaphylactic reactions was conducted using data from prehospital emergency missions performed by the Air Rescue Dresden/Germany from 2008 through 2015 using the standardized application protocol EPRO-5.0 (MIND 3) anonymized. Data from 152 adults and 29 children were evaluated, focusing especially on the acute treatment as well as demographic information, triggers, and symptoms of anaphylactic reactions.

RESULTS

In total, 152 adults (73 female, 79 male) from 18 to 87 years (mean 50.5 years) and 29 children (9 female, 20 male) from 1 to 16 years (mean 7.5 years) with anaphylactic reactions were analyzed. The most common trigger for severe anaphylactic reactions (Grade II-IV; classification modified according to Ring and Messmer) was food in children (33%) and insect venom in adults (59%). The data show that 19% of adults with Grade II-IV anaphylactic reactions (classification modified according to Ring and Messmer) received adrenaline. Regarding children, the appliance of adrenaline was only administered in seven percent of the cases of Grade II-IV anaphylactic reactions. Adults with Grade II or higher anaphylactic reactions were hospitalized in 92%. Three percent refused hospitalization and five percent were not transferred to hospital. One-hundred percent of the children with Grade II-IV anaphylaxis were hospitalized.

CONCLUSIONS

Analysis of data from the Air Rescue Dresden/Germany shows that despite existing recommendations, only 19% of adults with severe anaphylaxis received adrenaline. Among children, only in seven percent was a treatment with adrenaline performed.On the other hand, all patients survived the acute emergency treatment without apparent adverse outcomes. Thus, further studies are needed to determine the proper use of adrenaline in anaphylactic reactions.