Dr. Paul Ehrlich
I’m glad to know that more hospitals are following guideline treatments for asthma emergencies. 88% is better than the 71% a few years ago, although a 12% shortfall is disgraceful. But the real scandal is that there are millions of hospitalizations in the first place. If primary treatment for asthma followed guidelines even 88% of the time (the figure is closer to half that), emergency treatment would be a rare event, instead of a staple contributor to emergency room bottom lines all over the country.
The Sting: Everything You Need to Know About Insect Stings
Robert E. Reisman, M.D.
Allergic reactions to insect stings constitute a major medical problem, resulting in about 50 recognized fatalities annually in the United States and are likely responsible for other unexplained sudden deaths. People at risk often are very anxious about future stings and modify their daily living patterns and lifestyles. Recent advances have provided very effective treatment. For many affected people, this is a self-limited disease; for others, treatment results in a permanent cure.
THE INSECTS
The stinging insects may be broadly divided into 2 families: the vespids, which include the yellow jacket, hornet, and wasp; and the apids, which include the honeybee and bumblebee. People may be allergic to one or all of the stinging insects. The identification of the culprit insect responsible for these reactions is very important in terms of specific advice and specific venom immunotherapy treatment discussed later.
The honeybee and bumblebee are quite docile and tend to sting only when provoked. The honeybee usually loses its stinging mechanism in the sting process, thereby inflicting self-evisceration and death. The presence of the stinging apparatus in the skin after a sting usually, but not always, indicates the honeybee is the offending insect.
The yellow jacket is the most common cause of allergic insect sting reactions. These insects nest in the ground and are easily disturbed in the course of activities, such as lawn mowing and gardening. They are also attracted to food and commonly found around garbage and picnic areas. They are present in increasing numbers in late summer and fall months of the year. Hornets, which are closely related to the yellow jacket, nest in shrubs and are easily provoked by activities, such as hedge clipping. Wasps usually build honeycomb nests under eaves and rafters and are relatively few in number in such nests. In some parts of the country, such as Texas, they are the most common cause for insect stings.
In contrast to stinging insects, biting insects such as mosquitoes, rarely cause serious allergic reactions. These insects deposit salivary gland secretions, which have no relationship to venom deposited by stinging insects. Serious allergic reactions have occurred from the bites of some insects, such as the deerfly, blackfly, and bedbug. There are isolated reports that suggest, on rare occasions, mosquito bites can cause serious reactions. It is much more common, however, for insect bites to cause large local reactions.
REACTIONS TO INSECT STINGS
The usual reaction from an insect sting is mild redness and swelling at the sting site. This reaction is transient and disappears within several hours. Little treatment is usually needed, other than analgesics and cold compresses. Insect stings, in contrast to insect bites, always cause pain at the sting site.
LARGE LOCAL REACTIONS
Extensive swelling and erythema extending from the sting site, over a large area, is a fairly common reaction. The swelling usually reaches a maximum in 1 to 2 days and may last as long as 10 days. On occasion, fatigue, nausea, and malaise may accompany this large local reaction. Aspirin and antihistamines are usually adequate treatment. When severe or disabling, steroids, such as prednisone, may be very helpful. These large local reactions have been confused with infection and cellulitis. Insect sting sites are rarely infected and antibiotic therapy rarely indicated.
The natural history of large local reactions is that they are likely to recur after re-stings and the risk for more severe reactions is very low.
ANAPHYLAXIS–SEVERE REACTIONS
The most serious reaction that follows an insect sting is anaphylaxis. This occurs in anywhere from 0.5% to 3% of the population. Allergic reactions can occur at any age; most have occurred in individuals younger than age 20 and with a male to female ratio of 2:1. These factors may reflect exposure rather than any specific age or sex predilection. Reactions may occur after stings on any area of the body.
In most people serious anaphylactic symptoms occur within a short period after the sting. The clinical symptoms may vary from person to person and are typical of anaphylaxis from any cause. The most common symptoms involve the skin and include generalized urticaria, flushing, and swelling. More serious symptoms are respiratory and cardiovascular and include upper airway swelling, circulatory collapse with shock and hypotension, and bowel spasms.
There are no absolute criteria that will identify people at risk for acquiring venom allergy for the first time. Most people who have had severe reactions have tolerated stings in the past with no difficulty.
NATURAL HISTORY OF INSECT STING ANAPHYLAXIS
People who have had insect sting anaphylaxis have an approximate 60% recurrence rate after subsequent stings. Viewed from a different perspective, not all people presumed to be at risk react to re-stings. The incidence of these re-sting reactions is influenced by age and severity of symptoms of the initial reaction. In general, children are less likely to have a re-sting reaction as compared to adults. The more severe the initial allergic symptoms, the more likely it is to recur. People who have had severe reactions have a greater than 70% risk of another re-sting reaction.
DIAGNOSTIC TESTS
The typical allergy skin test is the diagnostic test of choice to determine suspect allergy. Individual honeybee, yellow jacket, hornet, and wasp venom extracts are available for diagnosis. There are also blood tests that can be used for measuring allergy. In general, the blood test is not as sensitive as the skin test.
THERAPY
People who have had a history of allergic reactions from an insect sting and have detectable positive venom skin tests or blood tests are considered at risk for subsequent reactions. Recommendations for therapy include measures to minimize exposure to insects, availability of emergency medication for medical treatment of an allergic reaction, and specific venom immunotherapy.
AVOIDANCE
The risk of insect stings may be minimized by the use of simple precautions. Individuals at risk should protect themselves with shoes and long pants or slacks when in grass or fields and should wear gloves when gardening. Cosmetics, perfumes, and hairsprays, which attract insects, should be avoided. Black and dark colors also attract insects; individuals at risk should choose white or light-colored clothes. Food and odors attract insects; thus, garbage should be well wrapped and covered and care should be taken with outdoor cooking and eating. Insect repellents are not effective against stinging insects.
MEDICAL THERAPY
Acute allergic reactions from insect stings are treated in the same manner as similar reactions which occur from any cause. People at risk should be self-taught to administer epinephrine and advised to keep epinephrine and antihistamines available. Epinephrine is available in preloaded syringes and can be administered easily.
VENOM IMMUNOTHERAPY
Venom immunotherapy (VIT) is highly effective in preventing subsequent sting reactions. Over 98% of people treated properly do not react when re-stung. VIT is administered to people who have had a history of insect sting reactions and have positive venom skin tests. Guidelines are available to define the adequate dose of venom, the duration of treatment, and criteria to determine when immunotherapy can be discontinued.
To summarize, stinging insect allergy is a potentially serious medical problem. Current treatment is remarkably effective.
Dr. Robert E. Reisman’s distinguished career spans more than 40 years, during which time he has been recognized for his extraordinary commitment to patient care and extensive research in the field of allergy and immunology. He joined the Buffalo Medical Group, PC, in 1988, and is board certified by the American Board of Internal Medicine and American Board of Allergy and Immunology. He is clinical professor of Medicine/Pediatrics at the University at Buffalo (UB) School of Medicine and Biomedical Sciences and an attending physician and allergist at Buffalo General Hospital and Women and Children’s Hospital of Buffalo. Dr. Reisman has authored or co-authored more than 200 articles, abstracts and book chapters, most of which address such clinically relevant issues as serum sickness, anaphylaxis, asthma, drug allergy, and in more recent years, stinging insect allergy. He is a Master in the American College of Physicians, and a Fellow and past president of the American Academy of Allergy, Asthma and Immunology, which honored him with its Distinguished Clinician Award in 2003. He was a member of the editorial board of the Journal of Allergy and Immunology and served on three Food and Drug Administration (FDA) committees related to allergens and vaccines.
Yellow jacket by adkinsbeeremoval.com
Eating Our Way to Asthma
By Dr. Larry Chiaramonte
In the South Bronx where I work, the rates of asthma are sky high, in large measure because of a high volume of diesel fumes from commercial traffic and cockroaches in homes. Properly treated and advised by doctors, patients do what they can to take their medicines and clean up their homes; these are things they can help. They tend to ignore the things they can’t help, like traffic, which is economically crucial to the neighborhood.
But asthma is not the only epidemic. The South Bronx also leads in obesity. And as with asthma, the rest of the country is following its lead. Why are we becoming too fat? I did a quick survey of a rehabilitated stretch of row houses nearby on afternoon. There were no children. No one riding bikes, jumping rope, playing stick ball. No one skating or using a skateboard. The playgrounds were empty. When I asked about this I received, “Doctor it is not safe for the kids, we rather have them play video games, or watch TV.” Mothers work and do not cook. Fast food has become the regular diet.
“Mechanical” factors associated with obesity, such as airway blockage, increase the frequency and severity of asthma. Obstructive sleep apnea—basically severe snoring as the airways are blocked and the body must jolt itself into breathing again–is in part due to obesity, and in turn aggravates the tendency to gain weight. Obstructive sleep apnea also increases the frequency and severity of asthma. These factors alone support the case for obesity being a causal agent for asthma.
But the association also extends to body chemistry itself. Researchers have compared the controls on the production of IgG [protective] and IgE [allergic] antibodies in normal and obese patients. They have found that fat cells promote IgE production disproportionately, making obese patients more “allergic” than is healthy. There is evidence that proinflammatory cytokines in fat tissue to contribute to both heart disease and asthma.
I know that Americans are weary of being told that they, and particularly their children, should get more exercise, eat less, and eat healthier foods. The consequences of this range of behavioral are thrown at us—hypertension, heart disease, diabetes. Now, you have to add asthma to this death spiral. It’s enough to make you drown your sorrows in a Big Mac and 32 ounces of soda. Don’t.
Allergy to Antibiotics
Q: A child comes in with a rash a few days after AMOXICILLIN is given for an ear infection. It is red, blotchy, and spreads across the body. It appears to be a drug reaction rather than a viral exanthem. Does this mean the child cannot take PENICILLIN in the future? Is the child restricted from trying any other “CILLIN” – DICLOXACILLIN, etc.
— Dr. L
Dear Dr. L,
The majority of side effects observed in AMOXICILLIN clinical trials were of a mild and transient nature and less than 3% of patients discontinued therapy because of drug-related side effects. The most frequently reported adverse effects were diarrhea/loose stools (9%), nausea (3%), skin rashes and urticaria (3%).
This is an “allergic reaction” but it is NOT related to a life threatening one. I think there is little risk if the child takes PENICILLIN in the future and should not be restricted from trying any other “CILLIN”, including DICLOXACILLIN.
Dr. Chiaramonte
Dr. Ehrlich adds:
I would add to this comment by Dr. Larry that there are those children who have Ampicillin reactions in the latter part of treatment, and many of those come from the non-allergic side effect of the drug (or Amoxicillin). Often their parents are told that the children have penicillin allergies, a misconception that they carry into adulthood.
Physicians Mailbag
Q: Many patients report a SULFA allergy–typically a rash. What is the chance that they will react to a diuretic like HYDROCHLOROTHIAZIDE
which as a sulfa moiety?
–Dr. L
Dear Dr. L
Skin testing to sulfa and many other drugs is not useful. The culprit-antigen is formed in the body when a breakdown product of the sulfa drug combines with a patient’s proteins. So I cheated a little and went to the Mayo Clinic website. This is a Quote:
“There are also a number of other medications related to sulfonamides. Although the medications noted below are probably safe for you to take if you have a sulfa allergy, you should first check with your doctor. Examples include, but are not limited to: Certain ‘water pills’ (diuretics), such as furosemide (Lasix) and hydrochlorothiazide (Microzide).”
So the cheating did not help me. I would like to know how bad the sulfa reaction was. Did the reaction occur with other sulfa drugs? If it did, how much medication was needed to cause a reaction? What was the time interval between taking the drug and having a reaction? This knowledge would help us do a challenge test.
We would give approximately a quarter dose of the DIURETIC and observe the patient twice as long as the time interval between taking the drug and having a reaction. Then we would increase the dose in a stepwise fashion until a full dose was reached without a reaction.
Dr. Chiaramonte
Smoke-Free Parks and Beaches–Good for Kids With Asthma
By Dr. Ehrlich
The New York Times this morning says that New York Mayor Michael Bloomberg intends to ratchet up his long anti-smoking campaign another notch, this time to include parks and beaches. Part of it is the gross spectacle of watching small children putting cigarette butts in their mouths before Mom has a chance to grab them away. But of course the worse element is the health effects. Health Commissioner Dr. Thomas Farley studied data for months and found “that someone seated within three feet of a smoker — even in the open air — was exposed to roughly the same levels of secondhand smoke as someone sitting indoors in the same situation.”
Naturally, smokers feel oppressed. As a former occasional smoker myself, I have been following the false personal liberty arguments for 50 years, brought to you by that pillar of bias-free science, the Tobacco Institute. But the case against second-hand smoke continues to accumulate. The New England Journal of Medicine reports a study on the incidence of childhood asthma after a ban on public smoking in Scotland in March 2006.
“Before the legislation was implemented, admissions for asthma were increasing at a mean rate of 5.2% per year (95% confidence interval [CI], 3.9 to 6.6). After implementation of the legislation, there was a mean reduction in the rate of admissions of 18.2% per year relative to the rate on March 26, 2006 (95% CI, 14.7 to 21.8; P<0.001). The reduction was apparent among both preschool and school-age children. There were no significant interactions between hospital admissions for asthma and age group, sex, urban or rural residence, region, or quintile of socioeconomic status.” Smoking cessation, both personal and second-hand, is one of many factors that contribute to the better care of asthma and allergies. I am reminded of a six year old boy whose chronic allergies and asthma caused many sleepless nights and missed school days. He attended a very aggressive school program in New York City, but quickly fell behind because of school absences and difficulty finishing assignments. After returning to school in the fall, mother came to me and was aware of two things. Her son did well while spending the summer with his grandparents in the country (no don't automatically blame city air pollution), and on his return to the apartment in New York he continued to do well. Mother ran into a neighbor on the elevator, and on the trip up learned that a couple who lived directly below her apartment--both heavy smokers--had moved. The neighbor noted that there was no more odor of smoke coming up through vents, and the mother quickly made the connection that that is why her son was feeling so much better: the lack of second-hand smoke from an adjacent apartment. To this day my patient is doing very well.
How Much Do You Know About Controlled Asthma?
By Dr. Paul Ehrlich
One of our primary goals here at Asthma Allergies Children World Headquarters is to provide primary care doctors, patients, and parents of patients with the knowledge to improve treatment for the children under their care because the ranks of allergists are dwindling while demand is growing. I was reminded of this when I went poking around the website of the Asthma and Allergy Foundations of America, AAFA.org—see the link in the left-hand column of our pages.
I found some links to an excellent program I helped them with a few years ago called SleepWorkPlay (there’s more about it in our book). The basic premise was that the effectiveness of asthma treatment can be best assessed by the quality of the patient’s sleep, work (or school), and play. Poor control takes a toll on each. AAFA commissioned Harris research to conduct a survey for both pediatric and adult patients. What they found was disturbing:
“Key results show that the majority of asthma patients and caregivers incorrectly believe that their asthma symptoms are under control. Furthermore, conversations about severity of symptoms and treatment do not appear to be taking place between many sufferers and their HCPs [health care providers]. For example, less than one in two sufferers’ HCPs (47%) and (66%) of caregivers’ HCPs have initiated conversations about when asthma is severe enough to call a doctor or go to an emergency room.
“Most Asthma Patients Over-Estimate Level of Control: a majority of asthma patients believe that their asthma is under control (88%), despite the fact that:
• 61% have had to catch their breath while running upstairs,
• 50% have had to stop exercising midway through their regimen
• 48% have been woken up in the middle of the night as a result of their asthma
“Parents Over-Estimate Child’s Level of Control: a majority of asthma caregivers believe that their child’s asthma is under control (89%), despite the fact that:
• 49% of their children have had to miss days of school and/or work
• 49% of their children have had to stop exercising midway through their regimen
• 45% of their children have been woken up in the middle of the night as a result of their asthma
“More Than Half of Asthma Patients Say Their HCPs Have Never Talked About Attack Procedures:
• Less than one in two sufferers’ HCPs (47%) have initiated conversations about when asthma is severe enough to call a doctor or go to an emergency room. This number is a little higher for the caregivers (66%)”
If you look at Dr. Chiaramonte’s response to a question in the Parents Mailbag, you will see a case in point. A young female college student had asthma and was asked to refrain from intramural sports because her asthma was uncontrolled. Her family doctor had given her a peak flow meter but never taught her how to use it. Yet, many elite athletes, including David (Bend it Like) Beckham, suffer from asthma. I believe this story is repeated over and over again, millions of times a year. It doesn’t have to be that way. We hope to work with AAFA to revive and promote the SleepWorkPlay program.
Thank you, Caroline Leavitt
After 30-years-plus in practice, it is not all that often that a patient’s testimony adds new perspective to my understanding of what patients go through. To tell you that I was undone by Caroline Leavitt’s guest editorial is an understatement. As someone who thrives on spending time with patients, their parents and significant others in order to learn how problems like asthma effects their lives, I felt as if I were sitting with her in my office. More importantly, I came away understanding her disease in ways that will add to my treatment from now on.
It is easy to talk of this disease in terms of pulmonary function tests, lost time at school or work, and the like, but going to the core of the problem is most important when treatment is to make a difference. I will think of Caroline Leavitt’s essay each time I look my patent or her/his parent in the examining room and ask, “How does this affect your life?”
Measuring Peak Flows: a How-To Manual
Q: My daughter was given a peak flow meter by her GP, along with several prescriptions, but no instructions on how to use it or interpret the results. While away at college, her asthma was bad, and she was disallowed from playing intramural sports. Can you please provide good instructions and tell us what the results mean?
Dr. Chiaramonte answers:
The most important instruction is that SHE MUST DO IT. It is more important to her health day-to-day than brushing her teeth, so one way to remind her to do it is to combine the two tasks; I would like her to do the toothbrush trick—attach her toothbrush with an elastic band to her peak flow meter as a morning reminder.
–The peak flow meter should read zero to start
–Use the peak flow meter while standing up straight
–Take in as deep a breath as possible
–Place the peak flow meter in the mouth, with the tongue under the mouthpiece
–Close the lips tightly around the mouthpiece
–She must refrain from “cheating” which she can do by putting her tongues near the whole which will give a falsely higher number.
–Blow out as hard and fast as possible; do not throw the head forward while blowing out
She should try to blow just a little bit harder than her normal exhalation on three attempts—it’s not like blowing up a balloon or blowing out a lot of birthday candles where you keep going till you feel lightheaded–and take the best reading of three.
Breathe a few normal breaths and then repeat the process two more times. Write down the highest number obtained. Do NOT average the numbers.
WHERE IS THE STARTING LINE? Unlike blood pressure or body temperature, there is no one “normal” measurement with peak flows. The best baseline is her personal best all-time peak flow, but we are initially forced to use her predicted peak flow without the knowledge of her best score until there’s more of a track record.
After that, 80% and up of the baseline would be a green normal zone. She can just take maintenance dosages if her medication.
60-80% of baseline would be a yellow cautionary zone –medication should be increased.
Below 60% of baseline would be a dangerous red zone-she should seek medical attention.
She should also work with her doctor to create an asthma action plan—see the link “Action Plan” in the upper right corner of this page–or click here.
You should also know that maximal peak flow number will go up as children get old and taller. A peak flow of 250 may be fine for an eight year old, but if it is still 250 at ten, that’s no good. Asthma Action Plans must be re-evaluated in children on a frequent basis.
As for intramural sports, David Beckham and many other elite athletes have asthma. Get it under control and go out and play!
Writing my way to asthma compassion
By Caroline Leavitt
Can writing heal? I’ve always written about the things that plagued or puzzled me, about the situations I wanted to better understand. But if you had told me that I would ever write about my childhood asthma, I’d never have believed it, because it was too shameful for me, too full of terrifying memories.
From the time I was five, I was sick. I was in and out of emergency rooms, in and out of hospitals, tethered to breathing machines. (I don’t know why I remember this, but at that time, the doctors kept calling the machine “the bird.”) I remember not being able to breathe, struggling to suck air through a windpipe that felt like a straw. And I remember the shame of having such a disease; the way I thought it was disgusting.
Asthma. It means “a lovely girl” in Japanese, but in Boston, where I grew up, I might as well have put a sign on my body that said “make fun of me” Kids giggled when they heard me wheeze and imitated the accordion sound, so I tried to suppress my breathing struggles, which made things worse. They made fun of my inhaler, so I lost it or hid it, once even tying it around my waist under my dress so no one would even know I had one. I withdrew. I couldn’t really run around outside with my friends anyway, so I spent long hours in the library, searching out biographies about other people who had overcome the tragic wrong turns of their body. I loved Helen Keller (“Big deal,” one of my friends said to me when he saw the book. “she was still deaf and dumb.”) I couldn’t carry my own inhaler, so there was the shame of having to ask the school nurse who would loudly ask me, “How’s the old asthma?” as if it were an uncle you weren’t so crazy about seeing. Worse, I had to ask my father for my inhaler at home. He would sigh and say, “Already?” But more painful was the way my mother watched me, her fear palpable, her voice full of warnings of all the foods, weather, dust, pets and more that she just knew would hurt me.
I stopped telling people that I had asthma because it sounded so shameful to me. So the next time I was sick, I told the teacher I had pleurisy, a word I learned from one of my library books. I begged my mother to not say the word asthma in notes excusing my absences, to say simply that I was ill. When I was in the hospital, I told friends it was bronchitis. The only way I could tell my first boyfriend, the love of my seventeen-year-old life that I had asthma, was to write him a letter about it and make him swear we wouldn’t have to talk about it after he read it.
I grew up and so, in a way, did my asthma. There were better medications, and when I got pregnant and had a child, my asthma miraculously seemed to grow milder.
And then I began to write this novel, Pictures of You. Pictures of You was about another phobia of mine, driving. Centering around a car crash, it had a little boy in it, and suddenly, to my surprise, he had asthma. “I don’t want to do this,” I told a friend. She laughed. “Then that’s why you should,” she told me.
So I began to create this life of this boy, Sam. Like me at ten, he hid or deliberately lost his inhalers. Like me, he was mocked and spent most of his time alone in the library, lost in books, and like me he was in out of emergency rooms. And as I was writing, to my surprise, my asthma began to get better. How could this be? I found I was taking less and less medication and then none at all. I went to my pulmonologist and told him, “I think I’m cured!”
“Asthma plays hide and seek,” he told me. “You can’t monkey around.” He insisted I keep taking my medication, but for me, writing this novel did more for me than steroids or albuterol. I began to fall in love with Sam, to feel so much sorrow and compassion for him, but the sicker he became, the better I felt. Right up until the moment I turned the book in, and then I got sick again! Emergency room sick! “I told you asthma plays hide and sick,” my doctor said.
I went back to normal, but something profound had changed. Suddenly, I was talking to people about the book, about Sam and his asthma, and that segued into me, for the first time, really talking about my asthma and me. What it had been like. What it was like now, right this minute. I didn’t heal my asthma, but I healed my childhood. By giving so much love and compassion to Sam, I gave it, in a way, to myself. Instead of feeling shame about the sick little girl I was, I now feel pride at how well I struggled through it, how brave I was. In a way, I claimed my asthma and in doing so, I made peace with it and with myself.
Caroline Leavitt is the author of 8 novels. Her 9th novel Pictures of You will be published by Algonquin Books in January. A book critic for People Magazine and the Boston Globe, she is a senior instructor at UCLA’s Writers Program online. She lives with her husband and son in Hoboken, N.J