Let's talk Anaphylaxis.

[NYMedic828]

Over in the ALS vs. BLS thread the topic of anaphylaxis was starting to get pretty heated so I made a thread at the request of abcKM.

Discuss anything anaphylaxis related...


My first question, in the event of severe laryngoedema, how much are the lower airways affected?

Do they only suffer mild inflammation and varying degree of bronchospasm mimicking asthma or can say, the bronhi become so inflamed they are entirely blocked?

 

[Epi-do]

Medically, I can't really answer your question. However, from personal experience, I can tell you for me it was quite a bit.

When I ended up in anaphylactic shock after taking Levaquin, I barely remember arriving at the ER, and don't remember anything after that. My understanding is that I was about as close as you can get to needing a tube, without actually needing one.

For the next several days, even with a steroid, inhalers, etc, I still had problems with wheezing, due to my asthma.

The entire experience certainly gave me a new perspective about treatment of my patients, if I happen to encounter this situation.

 

[NYMedic828]

Medically, I can't really answer your question. However, from personal experience, I can tell you for me it was quite a bit.

When I ended up in anaphylactic shock after taking Levaquin, I barely remember arriving at the ER, and don't remember anything after that. My understanding is that I was about as close as you can get to needing a tube, without actually needing one.

For the next several days, even with a steroid, inhalers, etc, I still had problems with wheezing, due to my asthma.

The entire experience certainly gave me a new perspective about treatment of my patients, if I happen to encounter this situation.

But is that wheeze due to bronchospasm/constriction of smooth muscle or is it due to actual fluid buildup and inflammation?

 

[Epi-do]

For me, it was bronchospasm. The anaphylaxis irritated my asthma, resulting in an increase in the number if episodes of bronchospasm I would have. Typically, as long as I use my daily maintenance meds for my asthma, I rarely have to ever resort to using the rescue inhaler. That wasn't the case for several days after the anaphylaxis.

I am sure the addition of the asthma complicates the answer to your question.

 

[VFlutter]

But is that wheeze due to bronchospasm/constriction of smooth muscle or is it due to actual fluid buildup and inflammation?

One or both. Anaphylaxis causes both bronchial smooth muscle constriction, or spasm, as well as swelling of upper airways. It is important to note the difference between wheezing and stridor. Wheezing occurs with bronchospasm and stridor with upper airway obstruction.



I will try to dig through my textbooks for a more detailed answer.

 

[Aprz]

I believe it causes the lower airway to constrict also. The upper airway has cartilage rings (I think cricoid is the last cartilage ring that's fully circumferential) that help prevent it from closing, but the lower airway doesn't.

 

[systemet]

I believe it causes the lower airway to constrict also. The upper airway has cartilage rings (I think cricoid is the last cartilage ring that's fully circumferential) that help prevent it from closing, but the lower airway doesn't.

The cricoid is the first ring, then the trachea is composed of a series of cartilaginous rings -- I believe there's some individual variation in the exact number. Soft tissue edema is the enemy in the upper airway in anaphylaxis.

 

[systemet]

My first question, in the event of severe laryngoedema, how much are the lower airways affected?

Do they only suffer mild inflammation and varying degree of bronchospasm mimicking asthma or can say, the bronhi become so inflamed they are entirely blocked?

I can't answer as to whether the bronchi can become completed occluded. I'm just ignorant as to the answer. But I can tell say that anaphylaxis can present in a number of different forms, and severe, life-threatening bronchospasm can be one of them.

Both histamine and a number of leukotrienes can cause bronchoconstriction. It's also remembering that asthma itself is a combination of chronic edema and airway hyperreactivity wiith episodes of acute bronchospasm.

There's also got to be a distinction made between pathologic events occuring in the trachea or bronchi and in the bronchioles.

 

[EpiEMS]

Anybody have BLS protocols for anaphylaxis that go beyond "routine patient care" and "administer an EpiPen"? Perhaps diphenhydramine PO, or administering a nebulized Beta-2 agonist?

 

[CANDawg]

Anybody have BLS protocols for anaphylaxis that go beyond "routine patient care" and "administer an EpiPen"? Perhaps diphenhydramine PO, or administering a nebulized Beta-2 agonist?

Here, BLS can draw up and administer IM Epi if there is no pen available, and administer salbutamol and ipratropium bromide via neb for bronchospasm. Diphenhydramine is ALS though. (Along with Prednisone, Dexamethasone, and for long transports, Dopamine.) ALS also can give epi SIVP/IO.

 

[Aprz]

The cricoid is the first ring, then the trachea is composed of a series of cartilaginous rings -- I believe there's some individual variation in the exact number. Soft tissue edema is the enemy in the upper airway in anaphylaxis.

But I mean the last ring that fully surrounds the soft tissue. Everything else below doesn't fully surround it, and as you get lower, it surrounds it less.

 

[leoemt]

But is that wheeze due to bronchospasm/constriction of smooth muscle or is it due to actual fluid buildup and inflammation?

Wouldn't fluid buildup be more Rales than Wheezing? I was always told that Rales is a sign of fluid in the lung

 

[Handsome Robb]

Wouldn't fluid buildup be more Rales than Wheezing? I was always told that Rales is a sign of fluid in the lung

If I'm not mistaken he's talking about edema associated with anaphylaxis secondary to the increased vascular permeability causing the pt to "third space" fluid into the tissues around the airways rather than pulmonary edema.

 

[Clare]

If I'm not mistaken he's talking about edema associated with anaphylaxis secondary to the increased vascular permeability causing the pt to "third space" fluid into the tissues around the airways rather than pulmonary edema.

Correct. Laryngeal edema will produce stridor, while the bronchoconstriction associated with release of histamine and other inflammatory factors will cause wheeze so you will likely hear frank stridor with wheeze upon auscultation provided both are present.

Nebulised adrenaline is part of the scope of practice for Emergency Medical Technician and intramuscular adrenaline is on the list of things to be added in the 2013 CPG review apparently. Paramedic may administer intramuscular adrenaline and Intensive Care Paramedic has both intramuscular and intravenous adrenaline.

 

[Handsome Robb]

But I mean the last ring that fully surrounds the soft tissue. Everything else below doesn't fully surround it, and as you get lower, it surrounds it less.

I was under the impression that the cricoid ring is the only complete circumferential tracheal ring but I've been plenty of times before. Hence cricoid pressure to compress the esophagus.

Wouldn't fluid buildup be more Rales than Wheezing? I was always told that Rales is a sign of fluid in the lung

Also, google "cardiac wheezing" in regards to APE causing wheezes.

 

[NYMedic828]

Wouldn't fluid buildup be more Rales than Wheezing? I was always told that Rales is a sign of fluid in the lung

Rales/crackles is a sign of fluid inside the actual passageways of the lungs. Edema is fluid inside the tissues.

Think of it like a garden hose. If the water is inside the house, it is rales/crackles and it prevents air from perfusing because the water is in the way.

If someone steps on the hose, it compresses the inside and blocks air from going anywhere. In the case of edema, the fluid is on the outside compressing the inside and causing blockage.

 

[systemet]

I was under the impression that the cricoid ring is the only complete circumferential tracheal ring but I've been plenty of times before. Hence cricoid pressure to compress the esophagus.

Both you and Aprz are right:

http://education.yahoo.com/reference/gray/subjects/subject/237

I'm wrong. Thanks for pointing that out

 

[mycrofft]

Rales/crackles is a sign of fluid inside the actual passageways of the lungs. Edema is fluid inside the tissues.

Think of it like a garden hose. If the water is inside the house, it is rales/crackles and it prevents air from perfusing because the water is in the way.

If someone steps on the hose, it compresses the inside and blocks air from going anywhere. In the case of edema, the fluid is on the outside compressing the inside and causing blockage.

TEACHING GRANDMA HOW TO STEAL EGGS:

Stridor: inspiratory, dry;air can't get in, ergo upper airway. (Lower airway embarassment, at least beyond the trachea, is not easy to hear because it is muffled). Made on inspiration. Often a "crowing" sound.

Wheeze: exhalatory, dry; air can't get out. More "windy" plus "harmonica" versus stridor. Usually bronchii and bronchioles in origin due to inflammation, exudation, and/or constriction. MOst adults can produce a forced end-expiratory wheeze for teaching purposes, but sit down, you might fall out.

"Rales" (glad that term is back): inhalatory, wet; tiny crackles made when tiny bronchioles and alveolii "pop" open as the gradient of ambient air pressure versus intra-bronchiolar or alveolar air pressure rises high enough to overcome the surface tension of exudate, serum or even water which is holding them shut. Each tiny crackle (think dribbling dry sand on a snare drum or empty coffee can) is an airway popping open.

"Rhoncii": gurgles on exhalation. Wet.

Swelling makes the walls of the "garden hose" thicker. Not usually without some fluid involved (leaking serum, thin pus). It swells inwardly and outwardly, and the inward swelling tends to decrease the caliber of the airway.

So the hose is sort-of being stepped on (stridor and wheezing), but someone poured bacon grease (well, serum/pus/exudate) down there and the goo is compounding the airway blockage (rales and rhoncii).

PULMONARY OEDEMA: http://www.nlm.nih.gov/medlineplus/ency/article/000140.htm FLuid back upm i the alveoli; and we know that wet alveoli will tend to (initially) make what sound?

And when there are no ralns nor rhoncii or stidor or wheezing, the pt is doing better right?

 

[leoemt]

Ah that makes sense. Still trying to learn my lung sounds, I've gotten pretty good but still got a lot more to learn.

 

[Aprz]

I was under the impression that the cricoid ring is the only complete circumferential tracheal ring but I've been plenty of times before. Hence cricoid pressure to compress the esophagus.

Yep, my bad. I was right and wrong. NVRob is right. It's the only one that completes it.

TEACHING GRANDMA HOW TO STEAL EGGS:

...

Thanks Mycrofft.