24.2 Allergic Rhinitis

Clinical Manifestations

Allergic rhinitis symptoms are persistent and vary seasonally. Rhinitis occurs as the result of an IgE-mediated immunologic response from an allergen transmitted through the respiratory tract. The number of patients with the allergic type of rhinitis rises with age and often appears with other disorders like asthma or cystic fibrosis. Allergic rhinitis can be severe and impedes a person’s sleep, leisure, educational or professional success, and overall quality of life. On average, affected patients miss 1 to 2 workdays a year due to chronic rhinitis (Rosenfeld et al., 2015).

The primary symptoms of allergic rhinitis are nasal congestion, sneezing, nose and throat itching, and abundant amounts of serous nasal drainage. Other symptoms may include itching, watery eyes, hyposomnia, headache, and post-nasal drip. Chronic cases can negatively impact quality of life by interfering with sleep, causing absences from school or work, and interfering with daily activities.

Diagnostics and Laboratory Values

Diagnostic tests include peripheral blood counts, total serum IgE, serum-specific IgE, nasal smears, nasal provocation tests, and epicutaneous (on the skin) and intradermal (just below the skin) skin testing. Nasal provocation tests are testing methods that reconstruct the upper airway response to natural exposure of irritants or allergens. Allergic causes of rhinitis will have elevated IgE and eosinophil. as well as positive allergen testing reactions. However, false-negative and false-positive skin testing results can occur and should therefore not be used alone to make a diagnosis.

Recognizing and Analyzing Cues

As part of recognizing and analyzing cues, the nurse should complete an assessment that includes a physical examination. The exam’s findings may reveal sneezing, itching eyes and nose, lacrimation, occasional headache, or thin, watery nasal discharge. The assessment should also describe the seasonal changes in symptoms, medication history, and nature of relevant antigens. The nurse should also obtain subjective data from the patient about how they felt prior to experiencing symptoms like difficulty breathing, wheezing, tingling sensations, pruritus, hoarseness, hives, rash, erythema, and edema. Finally, the nurse should assess any emotional distress the patient may be experiencing. Stress can exacerbate allergic symptoms by causing the body to release histamines, making symptoms worse. The nurse should also document the patient’s personal and family history of allergies, if any.

Prioritizing Hypotheses, Generating Solutions, and Taking Action

After documenting the findings from the examination and patient history, the nurse should verify orders received from the provider. Interventions may be aimed at improving breathing pattern, education, managing potential complications, and promoting home-based care. Nursing interventions for improving breathing pattern may include avoiding individuals with an upper respiratory infection and modifying the patient environment to reduce or prevent allergy symptoms. For example, the nurse should ensure the patient environment is free of fragrances, such as perfumes or certain lotions, that can cause an asthma attack. The nurse should also educate the patient on the importance of maintaining their medication or treatment regimen to minimize allergy symptoms, and on the risks of nonadherence to this regimen (e.g., allergy exacerbation). The nurse can help the patient identify barriers to adherence as well as alternative solutions to overcome these barriers.

The nurse must also ensure the patient and family understand that adherence in medications and treatments are essential. Any missed medication or appointments can interfere with dosage adjustments needed to reach a therapeutic range. This also includes educating the patients and families on medications for allergy maintenance, like leukotriene modifiers, versus rescue medications for allergy exacerbation or seasonal flares, like antihistamines. This is important to avoid building up a tolerance to the medications, so that the medication is effective when flareups or allergy exacerbations are evident.

Monitoring and managing potential complications are vital roles in nursing care. Patients with allergies are at risk for anaphylaxis or experiencing any difficulty breathing due to the reaction alone or medications. The nurse should monitor the patient’s respiratory rate and pattern (for example, signs of labored breathing, wheezing, shortness of breath, increased respiratory rate) and assess for abnormal lung sounds or any difficulty breathing. The patient’s pulse rate and rhythm should also be monitored. Emergency medications and equipment should be readily available in the event of anaphylaxis.

Discharge planning is always part of the nursing plan of care. The patient and family should be instructed on self-care at home, including correct usage of medications, adherence to treatment schedules, and the importance of minimizing exposure to allergens. The purpose, procedure, and schedule of any prescribed regimens from the provider should be reinforced to ensure the patient and their family members understand. Any side effects from medications or treatments should also be explained to the patient and family as well as each medication’s name, dosage, frequency, and actions.

Evaluating Outcomes

The nurse will want to evaluate expected outcomes for patients with allergic rhinitis. For example, the nurse can determine that the patient’s breathing pattern is adequate if lung sounds are clear on auscultation, respiratory rate and pattern are normal, and the patient denies any symptoms of respiratory distress. The nurse can determine that the patient understands their condition by having the patient verbalize or reiterate the teachings regarding diagnosis, medications, treatment, schedule, home care, and measures to avoid allergens. The patient should also be able to demonstrate how to properly administer their medications and to describe relevant signs and symptoms such as anaphylaxis, angioedema, difficulty swallowing, wheezing, difficulty breathing, peripheral tingling, and urticaria (hives).

Avoidance Therapy

Avoidance of triggers can be effective in decreasing symptoms of allergic rhinitis. Measures and environmental controls include:

• using air conditioners, humidifiers, dehumidifiers, and air cleaners
• removing dust-collecting items like knickknacks, books, soft toys, furnishings, carpets, and window coverings
• regularly washing bedding
• regularly cleaning the house (dusting, vacuuming, mopping)
• maintaining a pet-free home or bedroom
• using pillow and mattress covers that are resistant to dust mites
• maintaining a smoke-free environment
• changing clothes when returning from outdoors
• regularly showering to remove allergens from skin and air
• using a nasal irrigation device or saline spray to limit allergens in the nasal passages

High-efficiency particulate air purifiers and vacuum cleaner filters also aid in limiting the number of allergens in an environment. The use of multiple avoidance measures can greatly reduce the severity of symptoms. It is not possible to completely avoid allergen exposure, so other therapies (pharmacologic and immunotherapy) may be needed.

Pharmacologic Therapy

There are several pharmacologic options for treating allergic rhinitis. One type is an adrenergic agent, which is a vasoconstrictor of mucosal vessels that may be given orally or applied topically in the nasal or ophthalmic mucosal vessels; the topical route has fewer side effects, but prolonged use can lead to rebound congestion. Examples of adrenergic agents include Afrin (nasal), Alphagen P (ophthalmic), and Sudafed or pseudoephedrine (oral). Nasal decongestants are applied topically to relieve nasal congestion. This route activates the alpha-adrenergic receptor sites of the smooth muscle of the nasal mucosal blood vessels and reduces mucosal edema, fluid exudation, and local blood flow. Eyedrops may also be an effective treatment option to relieve symptoms of eye irritation such as itching, burning, dryness, or redness. Side effects may include dysrhythmias, palpitations, hypertension, irritability, tremor, central nervous system stimulation, and tachyphylaxis, which is the acceleration of hemodynamic status.

An antihistamine is classified as an H1 receptor antagonist, or blocker, and is used to manage mild allergy disorders. The H1 antagonists attach to H1 receptors and prevent histamine action at those sites. They do not prohibit mast cells from releasing histamine, and they have no effect on H2 receptors.

Oral antihistamines are readily absorbed and are the most effective when given at the initial onset of symptoms, as they can prevent new symptoms from arising. These medications are effective in certain patients with hay fever, urticaria, mild asthma, and vasomotor rhinitis. The side effects include drowsiness, dry mouth, agitation, anxiety, urinary retention, anorexia, blurred vision, nausea, and vomiting. Antihistamines are contraindicated in people who are nursing, newborns, pregnant people, children, older adults, and those who experience worsening conditions or symptoms.

Unlike the first-generation H1 receptor antagonists, such as Benadryl (diphenhydramine), the second-generation—or nonsedating—H1 receptor antagonists attach to peripheral rather than central nervous system H1 receptors. This leads to less sedation. Examples include Zyrtec (cetirizine), Claritin (loratadine), and Allegra (fexofenadine).

Antihistamines may be combined with a decongestant to decrease nasal congestion. Most are available over the counter, like cetirizine/pseudoephedrine (Zyrtec-D) and loratadine/pseudoephedrine (Claritin-D). Side effects may include increased blood pressure; therefore, long-term use should be avoided in those with hypertension.

Mast cell stabilizers are as effective as antihistamines but not as effective as intranasal corticosteroids. It may take a week before benefits are noticed. This type of medication is used prior to or at the initial onset of symptoms. Intranasal cromolyn sodium (NasalCrom) acts by stabilizing the mast cell membrane, which decreases histamine and other mediators release in the allergic response. It also prevents the action of macrophages, monocytes, eosinophils, and platelets involved in immune responses. This medication is not effective in nonallergic rhinitis. Side effects are usually mild and include local burning or stinging sensations and sneezing.

Intranasal corticosteroids may be used in more severe cases of allergic and perennial rhinitis that do not respond to decongestants, antihistamines, or intranasal cromolyn. The route of administration of this medication is by meter-spray devices. Examples of corticosteroids include triamcinolone (Nasacort), beclomethasone (Beconase, Qnasl), budesonide (Rhinocort), and flunisolide (AeroSpan).

Corticosteroids have anti-inflammatory properties and are effective in controlling or inhibiting allergic rhinitis major symptoms. (A topical decongestant may be needed to clear passages prior to intranasal corticosteroid administration if there are blockages.) These medications may take several days to two weeks to take full effect and should not be used for more than 30 days. Adverse effects include drying of the nasal mucosa as well as a burning or itching sensation from the meter-spray device. Corticosteroids can suppress the immune system and should therefore not be used in those with tuberculosis or untreated bacterial lung infections, as they can worsen the infection. This suppression of host defenses also increases the risk of infection in those who use corticosteroids.

Leukotriene modifiers affect the inflammatory cycle and are designed for long-term use. Patients may take these medications daily and may have a rescue medication to treat symptom exacerbation. Examples of leukotriene modifiers include montelukast (Singulair) or zafirlukast (Accolate). These medications work by blocking leukotriene production and action and preventing asthma symptoms.

Immunotherapy

The aim of immunotherapy is to desensitize an individual from allergies by treating IgE-mediated diseases by allergen extract injections. This allergy vaccine therapy involves gradually increasing the quantity of specific allergens to a patient until a therapeutic dose is reached. The therapeutic range is one that reduces the severity of symptoms a patient experiences with natural exposure to allergens. Immunotherapy is used as an adjunct therapy with symptomatic pharmacologic therapy and may be utilized when avoidance is not an option. The goals of this therapy include decreasing circulating levels of IgE, raising the level of blocking antibody IgG, and decreasing mediator cell sensitivity.

A positive skin test, positive allergy history, and the inability to avoid an allergen is indicative that immunotherapy is needed. This therapy may take three to five years to alter the allergic disorder. It can prevent the development or progression of allergy symptoms and asthma and is therefore considered to be a potentially preventive measure. It is essential that the patient understand immunotherapy as well as the significance of persisting with the therapy until immunocompetence is reached.

The three methods of immunotherapy include subcutaneous immunotherapy (SIT), epicutaneous immunotherapy (EPIT), and sublingual immunotherapy (SLIT). Immunotherapy should not be started during pregnancy; if a pregnant patient was already undergoing this immunotherapy prior to becoming pregnant, the dosage should not increase throughout the pregnancy. If a patient does not have a reduction in symptoms within one to two years, does not develop an increased tolerance to confirmed allergens, and is unable to reduce medication use to decrease symptoms, therapeutic failure is apparent. Failure of this therapy may be due to misdiagnosis, insufficient allergen doses, insufficient environmental controls, or newly evolved allergies.