Doctors Deficient in Anaphylaxis Care

Having just returned from the American College of Allergy, Asthma and Immunology (ACAAI) annual meeting, we’re spoiled for choice of news. But among all the science there was one stand out shocker.  In a session on Sunday, physicians presented the results of a survey, sponsored by the Asthma and Allergy Foundation of America (AAFA). During this, they revealed that a disturbingly high proportion of primary care and emergency physicians don’t know how to treat anaphylaxis.

Interviews with 318 physicians indicated that:

• substantial numbers do not always provide epinephrine to patients – even those  they believe are having anaphylactic reactions
• they often fail to refer anaphylaxis patients for follow-up care
• they believe incorrectly that some patients should not receive epinephrine auto-injectors

Myron Zitt, MD, says the results reveal “likely deficiencies in physician knowledge,” and corroborate results from earlier chart review studies.

In the telephone-based survey, researchers conducted interviews lasting an average of 19 minutes with approximately 100 emergency room physicians, 100 allergists, 50 adult primary care physicians, and 50 pediatricians.

82% to 99% of respondents in each group said they had treated at least one anaphylaxis case.

Although epinephrine is supposed to be given to all patients having such reactions, about 10% of emergency room physicians and 20% of primary care and pediatric physicians said they had done something else.  These “something else’s” included prescribed another drug, sending the patient to a hospital, or an “other” action.

Prescribing of auto-injectors for patients to take home also was far from universal. Barely 60% of emergency room physicians said they did. In fact, emergency physicians were generally bad at all phases of follow-up care. They rarely referred patients for diagnostic tests, they almost never demonstrated use of an auto-injector, and seldom explained that auto-injectors have an expiration date.

Another disturbing finding from the survey, Zitt said, was that many physicians of all types – even the allergists – mistakenly believed that some patients should never receive epinephrine.

In the same session, Akhil Chouksey, MD, reported that anaphylaxis care in a major teaching hospital usually failed to meet guidelines established by a consortium of allergy societies including the ACAAI.  In a 10-year review of anaphylaxis cases only 15% met the standards of care recommendations i.e. that epinephrine be administered within 30 minutes of triage, that auto-injectors be prescribed at discharge, and that patients be referred to an allergist or immunologist for follow-up investigations and treatment.

The review also found that in 26% of cases in which anaphylaxis was definitively confirmed, the patients never received epinephrine.  Antihistamines, such as benadryl (diphenhydramine), were given in nearly all cases but epinephrine was omitted in one-quarter. In fact, epinephrine was only the third most commonly administered medication, with corticosteroids such as methylprednisolone, taking the second spot after antihistamines.

During the question-and-answer period, an audience member suggested that, when patients present with relatively mild symptoms, the treating physicians may decide that epinephrine isn’t needed at that point.  Zitt countered, that this was a very dangerous approach.

The national guidelines state explicitly that there are no absolute contraindications to epinephrine. Nevertheless, 16% of the pediatric allergists and 32% of the other allergists said there were such contraindications, as did 38% of adult primary care and emergency physicians.

Also common were beliefs that schools, restaurants, and ambulances always stock epinephrine. In fact, Zitt said, there are no general requirements for schools or restaurants to do so, and approximately half of all ambulances do not have epinephrine on hand.

Clearly there is much work still to be done in terms of education.  SRxA’s Word on Health suggests a first step would be to instill a healthy fear of anaphylaxis into doctors and the general public while simultaneously removing the fear of epinephrine.

Or as Dr Zitt says, “Give epinephrine first, ask questions later.”

Nightmare on Allergy Street?

With Halloween rapidly approaching, do you have more than ghosts and ghouls and things that groan in the night to worry about?  If you suffer from seasonal allergies then your answer is almost certainly yes.

Seasonal allergies occur when outdoor allergens such as mold spores, tree, grass and weed pollen are inhaled and cause an allergic reaction.

This year allergy sufferers were subjected to the “perfect storm” of a mild winter, including an unseasonably warm February, and an early spring caused trees to pollinate earlier than normal.

“This has been a very strange year for allergies,” says Dr. David Chudwin, an allergist from Crystal Lake, IL. “It’s been the strangest year in the 30 years that I’ve been practicing.”

The early spring was followed by a hot dry summer that kept pollen counts high, day after day.  Then in late summer and early autumn, record-breaking mold counts resulted in county wide air-quality alerts that resulted in even mild allergy sufferers dreading the outdoors.  Although mold is typically associated with dampness, mold spores also are associated with dying vegetation.

Many molds grow on rotting logs and fallen leaves, in compost piles and on grasses and grains. Unlike pollens, molds do not die with the first killing frost. And mold counts can change quickly, depending on the weather. Certain spore types reach peak levels in dry, breezy weather. Some need high humidity, fog or dew to release spores. This group is abundant at night and during rainy periods.

To makes things worse, retreating indoors may not be the answer. For, those bothered by indoor, as well as outdoor, allergens, the season of suffering is just beginning.  As we start to run furnaces and our pets elect to curl up in front of the fire, dust and dander levels start to rise.

According to most of the country’s leading expert on allergies, more Americans than ever are sneezing, sniffling and itching. The Asthma and Allergy Foundation of America, estimates 450 million Americans suffer from allergies.

As previously reported by SRxA’s Word on Health, our squeaky clean lifestyle is probably to blame for the rising numbers.  According to the hygiene hypothesis – Children that lead too clean a life are not exposed to enough germs to properly adjust their immune system.

“People who are less prone to allergies include children from large families, children who live on farms, children in underdeveloped countries,” Chudwin said.

If you don’t fall into any of these categories, we suggest a trip to your local allergist, who can help prepare you for sneeze-free trick-or-treating and the other joys of fall and winter.

Improving Inhaler Instruction

Many of us have never been properly trained on how to do or use certain things we really should be good at. Putting on condoms and wearing seat belts are just two that come to mind.  And when we get them wrong, the health consequences can be serious.

The same goes for asthma inhaler use.  Do you shake the device first? Did you breathe in with sufficient force? Did you press the canister at the right time?

Improper use of inhalers is a serious and expensive problem. In the US, 3 patients are admitted to the emergency room with asthma every minute, that’s >5,000 people a day!  Worse still, according to the Asthma and Allergy Foundation of America, 11 people die from asthma every day.

One study estimated up to 94% of patients use their inhalers incorrectly.  The most common mistakes include failure to exhale before actuation, failure to breath-hold after inhalation, incorrect positioning of the inhaler, incorrect rotation sequence, and failure to execute a forceful and deep inhalation. Those of us in healthcare have even seen patients who fail to take the cap off the inhaler before use, and others who use it nasally rather than orally.

This is hardly surprising given that many patients never receive instructions on how to use their inhalers and even those that do, are not routinely followed.  And let’s face it, some of these devices could use training wheels.

Enter the T-Haler, a digital asthma inhaler training device  developed by researchers at Cambridge Consultants.

Patients with asthma can use the inhaler and, via interactive software linked to the wireless device, get real-time visual feedback on the areas that need improving.

Specifically, whether patients have shaken the device before breathing in; whether they use sufficient force when breathing in; and whether they press down the canister that releases the drug at the optimal time. Click here to see a video of the T-haler in action.

Although still a conceptual product, the company says it has been designed as a training device to be available at pharmacies, schools, and clinics for children and adults alike.

They performed a study on 50 people aged 18 – 60 who had no prior experience with either asthma or inhalers and were given no instruction on how to use an inhaler. When tested, about 80% of the participants used an inhaler incorrectly.

They were then given the T-Haler with no further instruction and told to begin. A three-minute on-screen tutorial guided them through the proper use of an inhaler, and the success rate tripled to more than 60%.

“Without any human direction beyond the word ‘go’, participants went from around a 20% success rate without training to a success rate of more than 60% after only three minutes with the T-Haler device,” said Kate Farrell, a senior design engineer, in a news release. “This is more than twice the compliance rate we have seen in other studies with trained participants. Interestingly, a week later, 55 percent were still correctly using the device-showing that they retained what they learned.”

Whether the T-Haler itself will ever make it to market remains to be seen, but the concept of a 3-minute training device seems a no-brainer when it comes to properly using a device that may very well save the lives of the estimated 235 million asthma sufferers worldwide.