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Allied health professionals gain treatment guidance:

Maureen George, PhD, RN, AE-C, FAAN

Cheryl Bernstein, RN, BSN, CCRC

The Allied Health Professionals Course returned to the ACAAI Annual Scientific Meeting with a day-and-a-half of expert lectures and workshops Nov. 9 and 10. General sessions tackled the basics of immunodeficiency, critical elements of asthma and COPD self-management, acute asthma management in the office setting, updates in anaphylaxis, stress and the immune system, advancing the care of patients with asthma, urticaria and angioedema, and food allergy research. Concurrent Workshops covered anaphylaxis, pulmonary function tests, sleep-disordered breathing in children, developing the clinical staff, extract preparation guidelines, and health literacy.

Maureen George, PhD, RN, AE-C, FAAN, assistant professor of nursing at the University of Pennsylvania, Philadelphia, looked at the similarities and differences between asthma and COPD in her presentation on “The Critical Elements of Asthma and COPD Self-Management: Exactly the Same and Completely Different.”

She described the prevalence and mortality, pathophysiology, risk factors, disease genesis, clinical presentation, diagnostic workup, components of self-management, and evidence-based recommendations for the self-management.

“Asthma and COPD are diseases that have some common features and also some uniquely different features, and if you understand these similarities and dissimilarities then you should be able to develop a tailored self-management plan for the patient,” said Dr. George, adding that beyond looking to the guidelines and evidence, treatment is about “evaluating the patient sitting across from you and making certain you figure out what the patient wants to do.”

“The goals from the EPR-3 (Expert Panel Report-3) say we should reduce impairment in the day-to-day burden of asthma and make certain that we reduce the risk of bad things happening.” she said. “And in COPD, the GOLD guidelines say to reduce symptoms and reduce risk.”

Keep risk in mind for those with COPD is vital. “It’s important because every COPD flare may cause the person to have a loss of quality of life, functional status, or lung function that may never be returned,” Dr. George said.

The stepwise treatment is different for asthma and COPD. In particular, inhaled corticosteroids are not added to the treatment of COPD until step C, while they are the first line of treatment for people with asthma.

“You don’t add inhaled corticosteroids with COPD until a patient’s FEV1 drops to 60 percent or lower because there is no evidence that inhaled steroids work in COPD if the FEV1 is greater than 60 percent,” Dr. George said.

Cheryl Bernstein, RN, BSN, CCRC, director of the Bernstein Clinical Research Center in Cincinnati, presented the “Extract Prep

Bernstein looked at the methods used to decrease the risk of bacterial contamination during extract preparation and mixing, the importance of becoming compliant with United States Pharmacopeia Chapter 797, and the qualifications and certification process of compounding personnel.

To be in compliance, compounding personnel must pass a written test on aseptic technique and extract preparation. “You can’t flunk the test. The reason you can’t flunk it is because if you have a wrong answer, the test will keep asking more questions until you pick the right answer. It’s not meant to be intimidating,” Bernstein said.

Other requirements are to have training in the preparation of allergenics; annually pass a media-fill test; demonstrate understanding of antiseptic hand cleaning and surface disinfection; be able to correctly identify, measure and mix ingredients; and be appropriately trained as professionals.

The guidelines also address physician responsibilities, that allergen extract dilutions must be bacteriostatic, dilutions must be prepared in accordance with the manufacturer’s instructions, potency issues, mixing of extracts with high and low proteolytic enzymes, storage, subcutaneous injections, aseptic techniques, prescriptions and labeling, mixing, and the policy and procedures manual.

Bernstein noted that after leaving the manufacturer, glycerinated patient vaccine vials expire three years later, while aqueous extracts expire 18 months later.

“You have to keep track and look at when they expire, and you have to follow the expiration date,” she said. “They really do lose potency.”

Lyophilized patient vaccine vials are aqueous extracts that have been freeze-dried to increase stability during storage and shipping. Once a solution has been added, she said, they become active as is the case with venoms, for example

“As you’re diluting these allergen extracts, the stability becomes vulnerable,” Bernstein said. “It is important to use human serum albumin in these because it coats the vial and prevents a protein from coming out. If you don’t use the HSA, then, over time, you’re giving the patient water.”

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