Allergy and Immunology

This document has been endorsed by the American Academy of Family Physicians and the American College of Allergy, Asthma and Immunology, and was developed in cooperation with the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine.

The specialty of family practice is interested in the care of patients with allergic and immunologic diseases, with an emphasis on comprehensive and continuing care. Each family physician should be aware of the impact of allergic/immunologic problems on the family and be willing and able to perform a preventive and therapeutic role with these patients. Environmental and occupational factors are significant in prevention. Interaction with the family members of any patient with allergies should be stressed in the education of the family physician.

It is expected that the family physician will become proficient in the diagnosis and treatment of patients with forms of allergic/immunologic diseases. The family physician may find it appropriate to seek consultation from an allergist/immunologist and actively engage in the co-management of the patient. In some cases, referral to an allergist/immunologist for management is indicated.

Knowledge

Immune response and hypersensitivity reactions
1. Biology of the immune response
  1. T lymphocytes
  2. B lymphocytes
  3. T and B cell functioning
  4. Cytokines
2. Immunology of IgE
3. Mast cells and basophil/mediator release
4. Complement
5. Classification of immune damage
  1. Type I, anaphylactic/immediate, late phase and dual reactions
  2. Type II, cytotoxic reaction
  3. Type III, Arthus reaction
  4. Type IV, delayed
  5. Type V, antireceptor
Immunodeficiency - primary and secondary
Asthma
1. Definition and severity evaluation
2. Impact on cost and quality of life for the patient and society
3. Major pathologic factors in airway obstruction (early and late phases)
  1. Inflammatory mucosal edema
  2. Bronchoconstriction (smooth muscle)
  3. Sputum secretions (mucus plugs)
  4. Airway remodeling
4. Triggers of symptoms
  1. Infection
  2. Irritants
    1. Tobacco smoke
    2. Atmospheric pollution
  3. Exercise
  4. Allergens
  5. Drugs
  6. Gastroesophageal reflux
  7. Acute emotional stress
5. Triggers of inflammation
  1. Allergens
  2. Occupational exposure
  3. Infection
6. Diagnosis and differential diagnosis
  1. History and physical examination
  2. Pulmonary function tests
  3. Allergy evaluation
  4. Methylcholine challenge
7. Pathophysiologic mechanisms
  1. Genetic factors (IgE)
  2. Autonomic dysfunction (adrenergic and cholinergic)
  3. Bronchial hyperreactivity (chemical mediators release)
8. Monitoring/peak flow
9. Preventive treatment
  1. Avoidance of triggers
  2. Immunotherapy
10. Medical treatment
  1. Beta₂ agonists
  2. Methylxanthines (theophylline)
  3. Anticholinergics
  4. Mast cell stabilizer
  5. Inhaled steroids
  6. Systemic steroids
  7. Leukotriene
  8. Other anti-inflammatory agents
11. Treatment of status asthmaticus
12. Management of asthma with concurrent conditions (e.g., pregnancy, hypertension, heart disease, surgery, diabetes mellitus)
13. Factors in compliance
  1. Education (especially inhaler techniques)
  2. Avoidance of environmental triggers such as tobacco smoke
  3. Early intervention of social and behavioral components
14. Morbidity and mortality
Rhinitis
1. Symptoms, signs, pathophysiology, quality of life
  1. Seasonal allergic rhinitis
  2. Perennial allergic rhinitis
  3. Perennial nonallergic rhinitis
  4. Vasomotor rhinitis
  5. Rhinitis medicomentosa
2. Triggers
  1. Inhalant allergens (household, outdoor environmental)
  2. Irritants
  3. Physiologic factors
  4. Endocrinologic factors
  5. Occupational agents
3. Diagnosis
  1. Nasal smears
  2. Skin testing
  3. In vitro testing (RAST)
4. Management
  1. Environmental
  2. Pharmacotherapy
    1. Antihistamines
    2. Sympathomimetics
    3. Mast cell stabilizer
    4. Inhaled steroids
    5. Systemic steroids
    6. Other anti-inflammatory drugs
    7. Anticholinergics
  3. Indications for immunotherapy
5. Associated conditions
  1. Sinusitis
  2. Orthodontic
  3. Otitis media, serous otitis media, nasal polyps, anosmia, allergic conjunctivitis
  4. Sleep disorders
Adverse reactions to foods, drugs and biologicals
1. Drugs
  1. Classification
    1. Toxicity
    2. Intolerance
    3. Side effects
    4. Allergic
    5. Interactions
    6. Genetic, enzymatic
    7. Idiosyncratic
  2. Diagnosis
    1. History and physical examination
    2. Skin testing
      1. Penicillin (IgE)
      2. Local anesthetics (therapeutic trial)
  3. Management
    1. Pharmocotherapy of acute reactions
    2. Avoidance
    3. Therapeutic desensitization
2. Food
  1. Classifications
    1. Toxicity
    2. Intolerance
    3. Physiologic reactions
    4. Genetic, enzymatic
    5. Allergic
    6. Additives
    7. Dermal allergy
  2. Diagnosis
    1. History and physical examination
    2. Skin testing
    3. In vitro testing
    4. Elimination diet
    5. Challenge diet
Dermatitis
1. Etiology/pathophysiology
  1. Allergic contact dermatitis
  2. Atopic dermatitis
2. Distribution and clinical characteristics
3. Patch testing
4. Management
  1. Avoidance/environmental control
  2. Soaks/baths
  3. Lubricants
  4. Steroids
  5. Antipruritic drugs
  6. Diet
Anaphylaxis
1. Precipitating factors
  1. Stinging insects
  2. Latex
  3. Drugs
2. Pathophysiology
3. Signs and symptoms
  1. Skin
  2. Respiratory
  3. Gastrointestinal tract
  4. Cardiovascular system
4. Diagnosis
5. Treatment
  1. Epinephrine
  2. Fluids
  3. Antihistamines (H₁, H₂)
  4. Steroids
  5. Vasopressors
  6. Endotrachael intubation
6. Prevention
  1. Patient education
    1. Anaphylactic kit
    2. Sting avoidance
    3. Sources of allergens, i.e., latex, drugs, foods
  2. Indications for venom immunotherapy
Urticaria/angioedema
1. Classification
  1. Acute urticaria/angioedema
  2. Recurrent acute urticaria
  3. Chronic urticaria
  4. Hereditary angioedema
2. Wheal and flare response
3. Immunologic mechanisms
4. Nonimmunologic mechanisms
5. Diagnosis
6. Management
  1. Environmental
  2. Diet
  3. Antihistamines
  4. Sympathomimetics
  5. Steroids

Skills

Skin testing
1. Puncture (prick)
2. Intradermal
3. Interfering conditions or medications
In vitro testing
1. IgE assay techniques
2. Methods of reporting
3. Interpretation, sensitivity, specificity
Pulmonary function tests
1. Common tests
  1. Peak expiratory flow rate (PEFR)
  2. Spirometry
    1. Forced expiratory flow (FEV)
    2. Force vital capacity (FVC) and forced expiratory flow in one second (FEV1)/FVC ratio
2. Diagram of lung capacities/flow volume loop
3. Typical findings in various conditions
4. Exercise challenge testing

Implementation

The development of core cognitive knowledge and appropriate skills in the care of the allergic patient should require experience in a structured educational component of a family practice residency program. There must be written goals and educational objectives. This need not be a "block rotation" but the educational experience must be appropriately identified and structured. Most of this experience will be in an outpatient setting with qualified physician teachers and allergy/immunology consultants.

If a block rotation is developed, a typical week of activities might include hospital rounds, departmental conference, informal discussion with the allergy/immunology consultant, evaluation of patients under the supervision of the allergy/immunology consultant and participation in administration of immunotherapy, skin testing and pulmonary-function tests. Time for detailed new and follow-up examinations of patients should be provided. Residents will obtain substantial additional clinical experience in allergy/immunology therapy throughout the three years of their experience in the family practice center.

References

Guidelines for the Diagnosis and Management of Asthma. National Heart, Lung, and Blood Institute, 1997.
Lawlor GL, Fisher TJ, Adelman DC, eds. Manual of Allergy and Immunology 3rd ed. Boston, MA: Little, Brown, 1995.
Middleton E, et al, eds. Allergy: Principles and Practice. Vol 1 and 2, 4th ed. St. Louis, MO: Mosby, 1993.
Primer on Allergic and Immunologic Diseases 4th ed. JAMA, 1997.

Web Sources

http://www.acaai.org

Published 6/89
Revised 7/95
Revised for review on 01-25-01