it is based on allergic rhinitis. very good study material.

2. INTRODUCTION
Allergic rhinitis is the most common form of respiratory allergy, which is presumed to be
mediated by an immediate immunologic reaction and is among top ten reasons to visit primary
providers.
The proportion of patients with the allergic form of rhinitis increases with age.
Early diagnosis and adequate treatment are essential to reduce complications and relieve
symptoms.

3. DEFINITION
• Allergic rhinitis is an IgE- mediated inflammatory nasal condition resulting from allergen
introduction in sensitized individual.
• Most common atopic allergic reaction.
• Affects 10 to 25% of population.
• Most commonly seen in young children and adolscents.

4. ETIOLOGY
It is classified as:
• Precipitating factors
• Predisposing factors

5. PRECIPITATING FACTORS
Aerobiological flora
• Allergens present in the environment
• House dust and dust mites
• Feathers
• Tobacco smoke
• Industrial chemicals
• Animal dander
Nasal physiology
• Disturbances in normal nasal cycle.

6. PREDISPOSING FACTORS
• GENETIC:
Multiple gene interactions are responsible for allergic phenomenon
Chromosome 5, 6, 11,12and 14 control inflammatory process in atopy.
50% of allergic rhinitis patients have a positive family history of allergic rhinitis.
• ENDOCRINE:
Puberty
Pregnant states and post partum stage
Menopause

7. • Psychological factors
• Focal sensitivity states
• Infections: fungal infection
• Age and sex
• IgA deficiency

8. COMMON ALLERGENS
Pollens
• Early spring: tree pollen ( oak, elm, poplar)
• Early summer: rose pollen( rose fever), grass pollen( Timothy, Redtop)
• Early Fall: weed pollen(ragweed)
Molds: Penicillium, cladosporium etc.
Insects: cockroaches, house flies, fleas, bed bugs.
Animals: cats, dogs, horse, monkeys, rats rabbitsetc
Dust mites: Dermatophagoides
Ingestants: nuts, fish, eggs, milk etc.

10. CLASSIFICATION
• Seasonal: Often known by it’s misnomer of hay fever.
• Summer cold: caused by virus causing URTI.
• Rose fever
• Perennial: allergens present throughout the year.
• Intermittent: symptoms present less than 4 days per week and less than 4 weeks per year.
• Mild: no interference with daily activity or troublesome symptoms.
• Moderate-severe: Impaired sleep, daily activity work.

11. PATHOPHYSIOLOGY
• Sensitization begins by ingestion or inhalation of an antigen.
• On re- exposure, the nasal mucosa reacts by slowing of ciliary action, edema formation and
leukocyte infiltration.
• Histamine is the major mediator of allergic reaction in the nasal mucosa.
• Tissue edema results from vasodilation and increased capillary permeability.

12. CLINICAL MANIFESTATIONS
• Sneezing
• Nasal congestion
• Rhinorrhea
• Post nasal drip
• Headache
• Earache
• Tearing of eyes
• Fatigue
• Drowsiness
• malaise

13. ASSESSMENT AND DIAGNOSTIC FINDINGS
• History
• Physical examination
• Diagnostic tests: epicutaneous and Intradermal testing.
• Nasal smears
• total serum IgE
• RAST
• Nasal provocation tests.

14. COMPLICATIONS
• Allergic Asthma
• Chronic Otitis Media
• Hearing loss
• Chronic nasal obstruction
• Sinusitis
• Orthodontic malocclusion in children
• Allergic conjunctivitis
• Anosmia ( loss of sense of smell)

15. MEDICAL MANAGEMENT
• The goal of the therapy is to provide relief from symptoms.
• Therapy may include one or all of the following interventions:
oAvoidance therapy
oPharmacologic therapy
oImmunotherapy
• Verbal instructions must be reinforced by written information.

16. AVOIDANCE THERAPY
• In avoidance therapy, every attempt is made to remove the allergens that act as precipitating factors.
• Simple measures and environmental control are effective in decreasing symptoms. Examples include:
the use of air conditioners, air cleaners, humidifiers and dehumidifiers
Removal of dust catching furnishings, carpets and window coverings.
Removal of pets from the home or bedrooms.
The use of pillow and mattress covers that are impermeable to dust mites
A smoke free environment
Change clothing coming from outside, showering to wash allergens from skin and hair.
Use saline nasal spray to reduce allergens in the nasal passages.
High efficiency particulate air ( HEPA) purifiers and vacuum cleaner filters may also be used to reduce the
allergens in environment.

17. PHARMACOLOGIC THERAPY
ANTIHISTAMINES:
• Classified as 𝐻1 receptor antagonists, used in the management of mild allergic disorders.
• 𝐻1 blockers bind selectively to 𝐻1receptors, preventing the actions of histamines at these sites. They do not
prevent the release of the histamine from mast cells or basophils.
• The 𝐻1 antagonists have no effect on 𝐻2 receptors, but they do have the ability to bind to nonhistaminic
receptors.
• Oral antihistamines, which are readily absorbed, are most effective when given at first occurrence of symptoms.
• Major class of medications prescribed for the symptomatic relief of allergic rhinitis.
• Antihistamines are contraindicated during the third trimester of pregnancy, in nursing mothers and newborns; in
children and older people and in patients whose conditions may be aggravated by muscarinic blockade.

18. • The side effects include: nervousness, tremors, dizziness, dry mouth, palpitations, anorexia,
nausea and vomiting.
• Second- generation or nonsedating 𝐻1 receptor antagonists are newer types of antihistamines.
• Unlike first generation, they do not cross the blood- brain barrier and do not bind to cholinergic,
serotonergic or alpha- adrenergic receptors.
• They bind to peripheral rather than central nervous system 𝐻1 receptors.
• Examples: loratadine, cetirizine, fexofenadine.
ADRENERGIC AGENTS:
• They are vaso- constrictors of mucosal vessels.
• Used in nasal ( Afrin) and ophthalmic ( Alphagan P) formulations in addition to the oral route (
pseudoephedrine).

19. • Adrenergic nasal decongestants are applied topically to the nasal mucosa for the relief of nasal
congestion. They activate the alpha- adrenergic receptor sites on the smooth muscle of the nasal
mucosal blood vessels, reducing blood flow, fluid exudation and mucosal edema.
• Potential side effects include: hypertension, dysrhythmias, palpitations, central nervous system
stimulation, irritability, tremor and tachyphylaxis.
MAST CELL STABILIZERS
• Intranasal cromolyn sodium ( NasalCrom) is a spray that acts by stabilizing the mast cell membrane thus
reducing the release of histamine and other mediators of the allergic response.
• In addition, it inhibits macrophages, eosinophils, monocytes and monocytes and platelets involved in
the immune response.

20. CORTICOSTEROIDS
• Intranasal corticosteroids are indicated in more severe cases of allergic and perennial rhinitis that
cannot be controlled by more conventional medications.
• Example include: beclomethasone, budesonide, dexamethasone, flunisolide, fluticasone and
triamcinolone.
• Because of their anti- inflammatory actions, corticosteroids are equally effective in preventing or
suppressing the major symptoms of allergic rhinitis.
• As the corticosteroids suppress host defenses, they must be used with caution in patient with
tuberculosis or untreated bacterial infections of the lungs.
• Patient taking corticosteroids are at risk of infection and suppression of typical manifestations of
inflammation.

21. LEUKOTRIENE MODIFIERS:
• Leukotrienes have many effects on the inflammatory cycle.
• Leukotrienes modifiers are for long- term use, and patients should be advised to take their
medication daily.
Leukotriene modifier available formulations Frequency of dosing
Leukotriene- Receptor Antagonists
• Zafirlukast
• Montelukast
Tablets: 10mg; 20mg
Tablets: 10mg; chewable tablets:
4mg, 5mg.
Granules: 4mg/packet
Taken twice a day
Taken once a day in pm.
Leukotriene- receptor inhibitors:
Zileuton Tablets: 600mg extended release
Taken twice a day within 1 hour after
morning and evening meals.

22. IMMUNOTHERAPY
INDICATIONS:
• Allergic rhinitis, conjunctivitis or allergic asthma
• History to a systemic reaction to Hymenoptera and specific immunoglobulin E antibodies to Hymenoptera
venom.
• Desire to avoid the long- term use, potential adverse effects or costs of medication.
• Lack of control of symptoms by avoidance measures or the use of medications.
CONTRAINDICATION:
• Presence of significant pulmonary or cardiac disease.
• Inability of patient to recognize or report signs and symptoms of a systemic reaction.
• Absence of equipment or adequate personnel to respond to allergic reaction if one occurs.

23. NURSING DIAGNOSIS
• Ineffective breathing pattern related to allergic reaction.
• Deficient knowledge about allergy and the recommended modifications in lifestyle and self
care practices.
• Ineffective coping with chronicity of condition and need for environmental modification.

24. NURSING INTERVENTION
• Assess the vital signs of the patient.
• Improving breathing pattern.
• Promoting understanding of allergy and allergy control.
• Coping with chronic disorder.
• Monitor the patient closely after administration of new medications and exposure to new foods, contrast
agents .
• Instruct the patient to question all medications and new foods.
• Identify early manifestations of allergic reactions.

25. • Administer emergency treatment for allergic reactions.
• Educate the patient and family about emergency home management of allergic reaction.
• Educate the patient and family members about avoidance measures to reduce risk of exposure
to allergens.