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L’asma acuto nel bambino fernando maria de benedictis

L’asma acuto nel bambino fernando maria de benedictis. Age-related differences in clinical outcomes for acute asthma in the United States: 2006-2008. 1.813.000 visits for acute asthma from 470 ED 1.144 asthma-related deaths. 903. 204. 37.

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L’asma acuto nel bambino fernando maria de benedictis

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  1. L’asma acuto nel bambino fernando maria de benedictis

  2. Age-related differences in clinical outcomes for acute asthma in the United States: 2006-2008 1.813.000 visits for acute asthma from 470 ED 1.144 asthma-related deaths 903 204 37 167 annual asthma-related deaths among children in the US Asthma mortality in children appears to occur more often in the out-of-hospital setting Tsai, JACI 2012;129:1252

  3. Fatal and near-fatal asthma in children Retrospective chart review of 261 children aged 1 to 18 yrs, who received ventilation (near-fatal) or died (fatal) in 8 tertiary-care PICU in USA, 2005-2009 8% Newth, J Pediatr 2012;161:214

  4. Pediatric asthma death: the mild are at risk Analysis of 51 deaths due to asthma Only 18/51 children had spirometry in the previous year 33% 32% Robertson, Pediatr Pulmonol 1992;13:95

  5. Caso clinico Anna Maria, 14 anni Storia personale: - sporadici episodi asmatici dall’età di 4 anni - a 6 anni, prick test positivi per acari (+++) - da 6 a 10 anni trattamento irregolare con broncodilatatori e steroidi AR - da alcuni mesi frequenti episodi di wheezing e dispnea: «ASMA!» trattamento con broncodilatatori AR e steroidi per os - apparentemente OK nei periodi intercritici - spirometria normale

  6. In un’occasione, la ragazza giunge in PS con • respiro rumoroso acuto, dispnea e ansietà • - Frequenza respiratoria: 30/min. • - SpO2: 97% • - PEF: 50% predetto • - ABG analisi: paO2 = 65mmHg; paCO2 = 25 mmHg • Modesta risposta al broncodilatatore • …. ricovero

  7. Spirometria con curva flusso-volume (durante la fase acuta)

  8. Vocal cord dysfunction Normal inspiration Inspiration with paradoxical vocal cord adduction

  9. Dysfunctional breathing Normal SaO2 ! Hyperventilation syndrome in adolescents with and without asthma D’Alba, Pediatr Pulmonol 2015, online

  10. Clinical features of vocal cord dysfunction 95 hospitalized patients in whom VCD was diagnosed Predominantly young women VCD Severe VCD+ asthma Asthma (n. 42) (n.42) (n.53) Duration of symptoms (yr) 4.8 15.1 14.1 Prednisone (mg/day) 29.2 25.5 21.3 Duration of prednisone (yr) 4.3 3.3 4.1 ER visits (n./yr) 9.7 4.5 5.5 Hospital admissions (n./yr) 5.9 3.1 6.7 Patients intubated (n.) 12 12 12 Newman, AJRCCM 1995;152:1352

  11. Acute asthma: Memorandum • Is it asthma? Assessment of severity Treatment When to admit When to discharge

  12. When all think alike, no one thinks very much

  13. Acute asthma: Memorandum • Is it asthma? • Assessment of severity Treatment When to admit When to discharge

  14. FAST Physical examination History Assessment of severity Functional evaluation

  15. Acute asthma: 1- History Predisposing factors to severe attacks • History of rapidly evolving attacks • Two or more hospitalizations or ED visits in the last year • Previous intubation or admission to ICU • Regular or recently stopped treatment with oral steroids • Increased use of bronchodilators in the last weeks • Low aderence to treatment • Patients unable to recognize the severity of the episode • Low socioeconomic level - difficult access to Health Care

  16. Acute asthma: 2- Physical examination • Respiratory rate • Wheezing • Use of accessory muscle • Heart rate • Ability to speak • Mental status Acute asthma: 3- Functional evaluation • Pulse oxymetry • Blood gas analysis • Pulmonary function

  17. Valutazione di gravità dell’asma acuto La presenza di diversi parametri, ma non necessariamente tutti, indica la gravità dell’esacerbazione

  18. Acute asthma: Memorandum • Is it asthma? • Assessment of severity • Treatment When to admit When to discharge

  19. Acute asthma: initial treatment • Correct hypoxia • Relieve bronchoconstriction • Reduce inflammation • Maintain hydro-electrolyte balance

  20. Acute asthma: initial treatment • Correct hypoxia - Oxygen Relieve bronchoconstriction Reduce inflammation Maintain hydro-electrolyte balance

  21. Acute asthma: Oxygen • All episodes except for mild • Preferably by mask • Target SaO2 >92% The Venturi mask: • Easy to apply • Allows for constant FIO2 irrespective of the pattern of breathing • FIO2 concentrations from 24% up to 50-60%

  22. Acute asthma: initial treatment • Correct hypoxia - Oxygen • Relieve bronchoconstriction - Short-acting beta2-agonists Reduce inflammation Maintain hydro-electrolyte balance

  23. Nebulized salbutamol in acute asthma: importance of the dose and the frequency of the doses 0.3 mg/kg/hour continuous > 0.3 mg/kg/hour intermittent Papo, Crit Care Med 1993 0.15 mg/kg/20 min > 0.05 mg/kg/20 min Schuh, Pediatrics 1989 0.05 mg/kg/20 min> 0.15 mg/kg/hour Robertson, J Pediatr 1985 Frequent intermittent or continuous nebulization of salbutamol is the most effective treatment

  24. Holding chambers versus nebulisers for beta-agonists treatment of acute asthma 25 RCT – 1897 children 2-17 yrs • Hospital admissions were not affected by the method of delivery (RR: spacers vs nebulizers = 0.71 !!!) • Length of stay in the ED was significantly shorter when the spacers were used (70 min vs 103 min) • Pulmonary function was similar for the two delivery methods • Pulse rate (- 5%) and risk of developing tremor(RR: 0.64) were lower for spacers use Cates, Cochrane 2013

  25. Asthma: Short-acting beta2-agonists • Salbutamolis the basicdrug • Efficacyproved in allages • By inhalationroute – Fast onset of action • Single dose = 0.15 mg/Kg by nebulization = 100 mcg/5 kg by MDI+spacer • Repeatedintermittentdosesshould be administered • Frequency of administrationisrelated to severity • NebulizervsMDI+spacer: sameefficacy

  26. Acute asthma: initial treatment • Correcthypoxia - Oxygen • Relievebronchoconstriction - Short-acting beta2-agonists - Anticholinergics Reduce inflammation Maintainhydro-electrolyte balance

  27. Adding ipratropium to salbutamol in acute asthma: importance of the dose and the frequency of doses SLB 0.15 mg/kg/20 min ± IPR 250 mcg/20 min SLB 0.15 mg/kg/20 min + IPR 250 mcg/20 min Schuh, J Pediatr 1995 SLB 0.05 mg/kg/20 min ± IPR 250 mcg/20 min Reisman, JACI 1988 SLB 0.05 mg/kg/20 min ± IPR 250 mcg single dose Beck, J Pediat 1985 Adding ipratropium to salbutamol was always more effective than using salbutamol alone

  28. Anticholinergics in acute asthma: a metanalysis ED: 20 RCT, 2697 children 1-18 yrs Hospitalized: 4 RCT, 472 children 1-18 yrs In ED • Adding a single dose of inhaled anticholinergics to beta-2 agonists slightly improves lung function, but does not prevent hospital admission • Additing repeated doses of inhaled anticholinergics to beta-2 agonists improves clinical score and lung function, and reduces hospital admissions • The beneficial effects of adding anticholinergic agents to beta-2 agonists was evident especially for patients with moderate to severe asthma In hospital • Adding inhaled anticholinergics to beta-2 agonists shows no effect in duration of hospital stay and other outcomes. No adverse effects were reported. Rodrigo, Thorax 2005;60:740 Griffiths, Cochrane 2013 Vezina, Cochrane 2014

  29. Asthma: Anticholinergics • Ipratroprium bromide • Synergic effect with beta-2 agonists • By inhalation route - Moderately slow onset of action • Repeated intermittent doses in addition to salbutamol • Single dose: <4 yrs: 125-250 mcg; >4 yrs: 250-500 mcg • Frequency of administration is related to severity • Reserve for moderate to severe asthma in ED

  30. Acute asthma: initial treatment • Correct hypoxia - Oxygen • Relieve bronchoconstriction - Short-acting beta2-agonists - Anticholinergics • Reduce inflammation - Steroids Maintain hydro-electrolyte balance

  31. Acute asthma: Systemic steroids In Emergency Department - improve symptoms - improve oxygenation - improve pulmonary function - reduce hospitalization - reduce hospital stay - reduce relapses At home or in ambulatory setting - improve symptoms - reduce time of resolution of the episode - reduce the risk of health resource use de Benedictis, AJRCCM 2012;185:12

  32. Acute asthma: Systemic steroids • Unnecessary for mild attacks • Mandatory in patients with history of severe attacks • The improvement is not immediate - Use early, if necessary • The benefits are greatest in more severe asthma • Oral and parenteral administration have equivalent effect • A definite dose-response relationship is not evident • Use 1-2 mg/kg/die of prednisone or equivalent • No substantial differences in efficacy between compounds • 5 to 10 days usually sufficient - No need to taper the dose de Benedictis, AJRCCM 2012;185:12

  33. Effect of systemic steroids in acute asthma: a question of time Bhogal, Curr Opin Pulm Med 2013;19:73

  34. High-dose inhaled fluticasone vs oral prednisone in children with severe acute asthma 100 children aged 5-17 years with severe acute asthma (FEV1 <60%) Fluticasone 2 mg MDI+spacer vsPrednisone 2 mg/kg added to standard therapy in ED If discharge after 4 h: Fluticasone 500 mcg bid vs Prednisone 1 mg/kg, 7 days Schuh, NEJM 2000;343:689

  35. High-dose inhaled fluticasone vs oral prednisone in children with mild to moderate acute asthma 69 children, 5-17 years with mild to moderate acute asthma (FEV1 60 to 80%) Fluticasone 2 mg MDI+spacer vsPrednisone 2 mg/kg in ED In addition to standard therapy If discharge after 4 h: Fluticasone 500 mcg bid vs Prednisone 1 mg/kg, 7 days Relapse rate by 48 hours Fluticasone 12.5% Prednisone 0% Schuh, Pediatrics 2006;118:244

  36. Budesonide nebulization added to systemic prednisolone in acute asthma in children 906 children aged 2-12 years with moderate or severe acute asthma in ED Addition of budesonide 500 mcg/dose vs placebo to standard treatment (salbutamol + ipratropium (3 doses) + prednisolone 2 mg/kg) % p=0.03 p=0.03 Admission rate Change of asthma score from baseline Alangari, Chest 2014;145:772

  37. Acute asthma: initial treatment • Correct hypoxia - Oxygen • Relieve bronchoconstriction - Short-acting beta2-agonists - Anticholinergics • Reduce inflammation - Steroids • Maintain hydro-electrolyte and metabolic balance - Avoid fluid overload - Check glucose and potassium - Correct lactic acidosis

  38. How to manage the patient which does not improve after standard treatment?

  39. Acute asthma: subsequent treatment • Improve bronchodilation - Theophylline - Beta2 agonists (iv) - Epinephrine - Magnesium sulphate - Anesthetics • Reduce respiratory work load - Heliox • Mechanical ventilation

  40. Intravenous aminophylline in acute asthma in children:is there a role? When added to standard therapy, no significant effect vs placebo on: - Lungfunction Di Giulio, J Pediatr 1993;122:464 Carter, J Pediatr 1993;122:470 - Rapidity of clinicalimprovement Needleman, ArchPedAdolMed 1996;149:206 - Clinicalseverity score Nuhoglu, AnnAllAsthImmunol 1998;80:395 - Length of hospital stay Strauss, Pediatrics 1994;93:205 - More frequentadverseevents Our update is consistent with the original conclusions that the risk-benefit balance of intravenous aminophylline is unfavourable Nair, Cochrane 2012

  41. Addition of intravenous to inhaled beta2-agonists for (severe) acute asthma in children 2 RCT - 56 children • Shorter recovery time • Earlier discharge from ED • Improved pulmonary function • No advantage in length of stay in PICU Bogie, Pediatr Emerg Care 2007:23:355 • Higher proportion of tremor Browne, Lancet 1997;349:301 Travers, Cochrane 2012

  42. Intravenous magnesium sulfate in acute asthma in children: a meta-analysis 5 RCT – 182 children Odd ratio for hospitalization Cheuk, Arch Dis Child 2005;90:74

  43. Nebulized magnesium sulphate in acute severe asthma in children (MAGNETIC) 508 children unresponsive to standard treatment Nebulized MgSO4 151 mg every 20 min x 3 doses. vs Placebo in addition to salbutamol + ipratropium Primary outcome ASS at 60 min post-treatment: statistically lower in the MgSO4 group, but not clinically significant Secondary outcomes No difference between groups The effect of MgSO4 waslarger in children with more severe asthma Powell, Lancet Respir Med 2013;1:301

  44. Helium/Oxygen-driven albuterol nebulization in the treatment of children with acute asthma 30 children aged 2-18 yrs in ED Standard treatment + either heliox or oxygen for driving nebulization of bronchodilators Discharge 33% Discharge 83% Kim, Pediatrics 2005;116:1127

  45. Acute asthma: Memorandum • Is it asthma? • Assessment of severity • Treatment • When to admit When to discharge

  46. Acute asthma: Criteria for admission • History of previous severe attacks • Respiratory failure • Severe grading (clinical, oxygenation, functional) especially after 1 hour of treatment • Complications (pneumothorax, atelectasis) • Experience (!!??) The decision to admit or discharge a patient should be made within 4 hours after presentation to the ED !

  47. Acute asthma: Memorandum • Is it asthma? • Assessment of severity • Treatment • When to admit • When to discharge

  48. Acute asthma: Criteria for discharge after hospitalization • Need of beta-2 agonists less than 3-4 hours • PEF >75% of predicted or of “personal best” • SaO2 stable >94% • Patient stable (i.e. no nocturnal symptoms) for at least 24 h with therapy to prescribe at home

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