Manejo Consensuado y Eficiente del Asma en Pediatria PRACTALL Y GINA

1. Manejo Consensuado y Eficiente del Asma en Pediatria(PRACTALL Y GINA) Dr. H. Joel Velarde Neumologo UMAE 34

3. DEFINICION DE ASMA Asma es una enfermedad inflamatoria cr�nica que afecta a las v�as respiratorias perif�ricas, participando fundamentalmente las c�lulas cebadas y los eosin�filos, provocando un estado de hiperreactividad bronquial que se manifiesta, luego de los est�mulos provocadores, como un estado de broncoespasmo, el cual es reversible y autolimitado

4. STATUS DEL ASMA Tradicionalmente, el diagn�stico y tratamiento del asma infantil apenas se diferenciaba del de los adultos. La necesidad de abordar de forma espec�fica el asma en ni�os, con m�todos diagn�sticos y terap�uticos espec�ficos se debe al consenso Practall. Esta iniciativa de la Academia Europea de Alergolog�a e Inmunolog�a Cl�nica, en la que han participado 40 especialistas de 20 pa�ses, unifica los criterios y ofrece, por primera vez, una serie de recomendaciones internacionales para que el asma infantil se aborde de la misma forma en cualquier parte del mundo.

5. Tratamiento del asma

6. CLASIFICACION DEL ASMA

7. CONTROL DEL ASMA El 40% de los ni�os asm�ticos alcanzan un adecuado control de su enfermedad. Se considera no control a la presencia de sintomatolog�a por lo menos 4 veces en 2 semanas o bien manifestaciones nocturnas por lo menos en 2 ocasiones en un mes. Los pacientes con control sub�ptimo que adem�s no recurren a la medicaci�n de rescate, por lo menos 6 d�as de la semana son considerados como submedicados. Se revisaron 754 ni�os asm�ticos. 63% mostraban buen control. Entre los no controlados, el 48% usaban adecuadamente la medicaci�n de rescate. El 62% de los padres los consideraban controlados. 12% de los padres no coincid�an entre si en relaci�n con el control logrado. 35% de los padres consideraban a sus hijos como "intermitentes", sin reconocer la condici�n cr�nica alcanzada. 22% de los padres consideraron s�ntomas dos veces por semana como con buen control. Un control suboptimo fue reportado en el 51% de los chicos hispanos, 37% de los ni�os negros y en 32% de los ni�os blancos. Solo el 38% de los padres se�alaron que se les hab�a indicado que buscaran implementar medidas de control. Smith LA et al, Modifiable Risk Factors for Suboptimal Control and Controller Medication underuse among Children with asthma Pediatrics 2008, 122:760

8. ASMA EN PEDIATRIA El asma infantil presenta caracter�sticas propias que lo diferencian del asma en el adulto y que permiten establecer diferenciaciones entre los propios ni�os asm�ticos. Entre ellas se encuentra la historial natural de la enfermedad, la edad del ni�o, los factores desencadenantes (ejercicio f�sico, virus, al�rgenos, rinitis o el sobrepeso), as� como la respuesta al tratamiento farmacol�gico y su cumplimiento No hay que olvidar el proceso de desarrollo pulmonar, la inmadurez del sistema inmune y el tama�o de sus v�as a�reas

9. El grupo PRACTALL 44 Expertos en Asma Pedi�trica 20 pa�ses The PRACTALL Pediatric Consensus Report presents clinical information on asthma, the disease and its management, from the medical literature as of June 2007 and current best clinical practice from Europe and North America.1 The 44 participants in the report represented 20 countries on those 2 continents.1The PRACTALL Pediatric Consensus Report presents clinical information on asthma, the disease and its management, from the medical literature as of June 2007 and current best clinical practice from Europe and North America.1 The 44 participants in the report represented 20 countries on those 2 continents.1

11. PRACTALL

12. PRACTALL Diagn�stico sospechado en lactantes basado en observaci�n de sibilancias recurrentes y episodios de tos, en donde la evaluaci�n a largo plazo ser� necesaria para confirmar el diagn�stico.

13. PRACTALL Siempre debemos de manejar diagnosticos diferenciales de asma, y estar pendientes de la historia de patrones de sibilancias recurrentes. Siempre debemos de manejar diagnosticos diferenciales de asma, y estar pendientes de la historia de patrones de sibilancias recurrentes.

14. Tratamiento Farmac�logico (Ni�os <2 A�os) The Pediatric Consensus Report notes that the diagnosis and treatment of asthma in patients 0 to 2 years of age pose the greatest challenges due to the limited availability of clinical evidence.1 For example, there is no clear basis for determining how frequent a child�s obstructive episodes should be before the decision is made to initiate continuous therapy with an ICS or LTRA.1 The consensus report recommends that a diagnosis of asthma be considered in a child 2 years of age or younger who has had more than 3 documented episodes of reversible bronchial obstruction within a period of 6 months.1 For these children, intermittent therapy with a �2-agonist is recommended as first-line therapy despite conflicting evidence. In Europe, this therapy would be administered orally, whereas in the United States, therapy would be administered as inhalation therapy via jet nebulizers.1 An LTRA can be used as daily controller therapy on either a long- or short-term basis for children 2 years of age or younger who have viral wheezing.1 Nebulized corticosteroids or ICS therapy delivered via metered-dose inhalers with spacers are recommended as daily controller therapy in these young patients who have persistent asthma. This is particularly relevant in cases of severe disease or those that require frequent use of oral corticosteroids. Evidence of atopy and allergy in these cases should lower the decision threshold for the use of ICS, which may be considered for first-line therapy.1 Oral corticosteroids, such as prednisone 1 to 2 mg/kg/day for 3 to 5 days, may be appropriate in children 2 years of age or younger who experience acute and frequently recurrent obstructive episodes.1The Pediatric Consensus Report notes that the diagnosis and treatment of asthma in patients 0 to 2 years of age pose the greatest challenges due to the limited availability of clinical evidence.1 For example, there is no clear basis for determining how frequent a child�s obstructive episodes should be before the decision is made to initiate continuous therapy with an ICS or LTRA.1 The consensus report recommends that a diagnosis of asthma be considered in a child 2 years of age or younger who has had more than 3 documented episodes of reversible bronchial obstruction within a period of 6 months.1 For these children, intermittent therapy with a �2-agonist is recommended as first-line therapy despite conflicting evidence. In Europe, this therapy would be administered orally, whereas in the United States, therapy would be administered as inhalation therapy via jet nebulizers.1 An LTRA can be used as daily controller therapy on either a long- or short-term basis for children 2 years of age or younger who have viral wheezing.1 Nebulized corticosteroids or ICS therapy delivered via metered-dose inhalers with spacers are recommended as daily controller therapy in these young patients who have persistent asthma. This is particularly relevant in cases of severe disease or those that require frequent use of oral corticosteroids. Evidence of atopy and allergy in these cases should lower the decision threshold for the use of ICS, which may be considered for first-line therapy.1 Oral corticosteroids, such as prednisone 1 to 2 mg/kg/day for 3 to 5 days, may be appropriate in children 2 years of age or younger who experience acute and frequently recurrent obstructive episodes.1

15. PRACTALL Tratamiento Farmac�logico (Ni�os >2 A�os) The approach to pharmacologic treatment of asthma recommended for children older than 2 years of age in the Pediatric Consensus Report is summarized in this slide. The approach is based on first-line therapies followed by a series of step-ups to more-intensive therapy to overcome insufficient control and step-downs to less-intensive therapy, if appropriate.1 First-line controller therapy may involve either an inhaled corticosteroid (ICS), at a dose of 200 �g of beclomethasone dipropionate equivalent, or a leukotriene receptor antagonist (LTRA) at an age-dependent dose in pediatric patients with persistent asthma. An LTRA may be an especially appropriate choice in patients with concomitant asthma and rhinitis.1 Evidence of insufficient control with first-line therapy should prompt the treating physician to ask the patient, parent, and/or caregivers about compliance with prescribed therapy and allergen avoidance, and to reevaluate the patient�s diagnosis of asthma.1 For pediatric patients confirmed to have uncontrolled asthma, the ICS dose could be doubled or an ICS could be added to LTRA therapy. Continued failure to achieve asthma control should prompt the physician to ask again about compliance issues and consider referring the patient to a specialist. Therapeutic options at this point include doubling the ICS dose again, adding an LTRA to ICS therapy, or adding a long-acting ?2-agonist (LABA).1 Safety concerns with LABAs have been raised recently, suggesting that their use should be restricted to add-on therapy to ICS when indicated.1 Subsequent failure to achieve asthma control in pediatric patients may necessitate the use of theophylline or oral corticosteroids.1 The approach to pharmacologic treatment of asthma recommended for children older than 2 years of age in the Pediatric Consensus Report is summarized in this slide. The approach is based on first-line therapies followed by a series of step-ups to more-intensive therapy to overcome insufficient control and step-downs to less-intensive therapy, if appropriate.1 First-line controller therapy may involve either an inhaled corticosteroid (ICS), at a dose of 200 �g of beclomethasone dipropionate equivalent, or a leukotriene receptor antagonist (LTRA) at an age-dependent dose in pediatric patients with persistent asthma. An LTRA may be an especially appropriate choice in patients with concomitant asthma and rhinitis.1 Evidence of insufficient control with first-line therapy should prompt the treating physician to ask the patient, parent, and/or caregivers about compliance with prescribed therapy and allergen avoidance, and to reevaluate the patient�s diagnosis of asthma.1 For pediatric patients confirmed to have uncontrolled asthma, the ICS dose could be doubled or an ICS could be added to LTRA therapy. Continued failure to achieve asthma control should prompt the physician to ask again about compliance issues and consider referring the patient to a specialist. Therapeutic options at this point include doubling the ICS dose again, adding an LTRA to ICS therapy, or adding a long-acting ?2-agonist (LABA).1 Safety concerns with LABAs have been raised recently, suggesting that their use should be restricted to add-on therapy to ICS when indicated.1 Subsequent failure to achieve asthma control in pediatric patients may necessitate the use of theophylline or oral corticosteroids.1

16. PRACTALL Recomienda ya sea CSI o LTRAs como Controladores Iniciales para Asma Como primera l�nea de tratamiento para asma persistente Debe iniciarse como tratamiento de mantenimiento cuando el control de asma no es adecuado Atopia y PFP predicen respuesta favorable En caso de control inadecuado, identificar las razones. En caso indicado, considerar incrementar la dosis de CSI o agregar LTRAs o bAAP El beneficio observado en ni�os mayores desaparece al descontinuar la terapia Nueva evidencia no apoya un rol modificador en la enfermedad al suspender el tratamiento en preescolares The goals of pharmacotherapy in pediatric patients with asthma are to control symptoms and prevent exacerbations with minimal adverse effects. The specific goal of regular controller therapy should be to reduce bronchial inflammation in these patients, because appropriate treatment of airway inflammation is known to lead to optimal asthma control. Two controller medications featured in the algorithm for preventive treatment in the Pediatric Consensus Report are ICS and LTRAs.1 ICS reduce the frequency and severity of asthma exacerbations. Therapy with an ICS should be initiated at a dose equivalent to 200 �g of beclomethasone dipropionate in patients who experience inadequate asthma control with reliever medications alone. If, after 1 to 2 months of initial low-dose ICS therapy, asthma control remains inadequate, the reason for poor control should be identified and the clinician should consider either increasing the ICS dose or adding an LTRA or LABA. The Pediatric Consensus Report notes that it is well known that the benefit of ICS therapy begins to disappear as soon as treatment is discontinued in older children. Additionally, newly available evidence does not support a disease-modifying role for ICS therapy after cessation of treatment in preschool children. Predictors of favorable response to ICS therapy include atopy and poor lung function prior to initiation of therapy.1 The Pediatric Consensus Report states that LTRAs are an alternative first-line treatment for persistent asthma in pediatric patients. Clinical evidence supports the use of oral montelukast for initial controller therapy in children with mild asthma: it provides bronchoprotection and reduces airway inflammation, as measured by nitric oxide levels, in some preschool children with allergic asthma.1 Two factors may be considered as predictors of a favorable response to LTRA therapy. These factors are a younger age (<10 years) and a high level of urinary leukotrienes.1 LTRAs may be particularly appropriate choices in several clinical situations, including the following: patients who cannot or will not use an ICS; patients who could benefit from add-on therapy to ICS, due to the different and complementary mechanisms of action of these agents; patients with concomitant rhinitis; patients with viral-induced wheeze; and, in children 2 to 5 years of age, to reduce the frequency of asthma exacerbations. It should be noted that the benefit of LTRA therapy has been demonstrated in children as young as 6 months of age.1The goals of pharmacotherapy in pediatric patients with asthma are to control symptoms and prevent exacerbations with minimal adverse effects. The specific goal of regular controller therapy should be to reduce bronchial inflammation in these patients, because appropriate treatment of airway inflammation is known to lead to optimal asthma control. Two controller medications featured in the algorithm for preventive treatment in the Pediatric Consensus Report are ICS and LTRAs.1 ICS reduce the frequency and severity of asthma exacerbations. Therapy with an ICS should be initiated at a dose equivalent to 200 �g of beclomethasone dipropionate in patients who experience inadequate asthma control with reliever medications alone. If, after 1 to 2 months of initial low-dose ICS therapy, asthma control remains inadequate, the reason for poor control should be identified and the clinician should consider either increasing the ICS dose or adding an LTRA or LABA. The Pediatric Consensus Report notes that it is well known that the benefit of ICS therapy begins to disappear as soon as treatment is discontinued in older children. Additionally, newly available evidence does not support a disease-modifying role for ICS therapy after cessation of treatment in preschool children. Predictors of favorable response to ICS therapy include atopy and poor lung function prior to initiation of therapy.1 The Pediatric Consensus Report states that LTRAs are an alternative first-line treatment for persistent asthma in pediatric patients. Clinical evidence supports the use of oral montelukast for initial controller therapy in children with mild asthma: it provides bronchoprotection and reduces airway inflammation, as measured by nitric oxide levels, in some preschool children with allergic asthma.1 Two factors may be considered as predictors of a favorable response to LTRA therapy. These factors are a younger age (<10 years) and a high level of urinary leukotrienes.1 LTRAs may be particularly appropriate choices in several clinical situations, including the following: patients who cannot or will not use an ICS; patients who could benefit from add-on therapy to ICS, due to the different and complementary mechanisms of action of these agents; patients with concomitant rhinitis; patients with viral-induced wheeze; and, in children 2 to 5 years of age, to reduce the frequency of asthma exacerbations. It should be noted that the benefit of LTRA therapy has been demonstrated in children as young as 6 months of age.1

17. PRACTALL Identificaci�n del Tipo de Asma Various asthma phenotypes can be defined on the basis of the child�s age and asthma triggers. Recognition of these different phenotypes and disease severity can help provide better direction for prognosis and therapeutic strategies.1 This slide summarizes an approach to determining asthma phenotypes in children older than 2 years of age. In this approach, the initial question is based on whether the child is completely well between symptomatic periods.1 If the child is well beween such periods, possible phenotypes are virus-induced asthma and exercise-induced asthma, depending on the precipitating factors. For either of these phenotypes, the possibility that the child may also be atopic must be explored.1 The child who is not completely well between symptomatic periods and does not meet the criteria for virus- or exercise-induced asthma may have clinically relevant allergic sensitization. In this case, the child may have allergen-induced asthma or unresolved asthma. In the latter case, different etiologies, including irritant exposure and as-yet not evident allergies, may need to be considered.1 Among preschool children 3 to 5 years of age, persistence of asthma symptoms during the year can be a key differentiator of asthma phenotype. Since viruses are the most common trigger in these children, viral-induced asthma is an appropriate diagnosis among these patients whose symptoms disappear completely between episodes and usually recur following a cold. The phenotype of exercise-induced asthma can also be observed in this age group.1 Tests for the presence of specific immunoglobin E (IgE) antibodies, such as skin prick or in vitro tests, should be performed to obtain information that may supplement clinical information regarding a relationship between exposure to a potential allergen and the occurrence of asthma symptoms. Findings of such antibodies are consistent with the phenotype of allergen-induced asthma. The Pediatric Consensus Report emphasized that atopy is a risk factor for the persistence of asthma, regardless of any observation that allergens are or are not obvious triggers of disease activity in an individual child. The absence of a specific allergic trigger may indicate a phenotype of nonallergic asthma. The clinician should consider this phenotype with caution, however, since the failure to identify an allergic trigger may reflect the fact that a specific allergic trigger was not detected.1 Among school-age children 6 to 12 years of age, the differentiators of asthma phenotypes are identical to those in younger children; however, the clinician should consider that cases of allergen-induced asthma are more common and visible in the older children, and seasonality may be a more evident factor. Finally, virus-induced asthma should also be considered in these children since it is still common.1Various asthma phenotypes can be defined on the basis of the child�s age and asthma triggers. Recognition of these different phenotypes and disease severity can help provide better direction for prognosis and therapeutic strategies.1 This slide summarizes an approach to determining asthma phenotypes in children older than 2 years of age. In this approach, the initial question is based on whether the child is completely well between symptomatic periods.1 If the child is well beween such periods, possible phenotypes are virus-induced asthma and exercise-induced asthma, depending on the precipitating factors. For either of these phenotypes, the possibility that the child may also be atopic must be explored.1 The child who is not completely well between symptomatic periods and does not meet the criteria for virus- or exercise-induced asthma may have clinically relevant allergic sensitization. In this case, the child may have allergen-induced asthma or unresolved asthma. In the latter case, different etiologies, including irritant exposure and as-yet not evident allergies, may need to be considered.1 Among preschool children 3 to 5 years of age, persistence of asthma symptoms during the year can be a key differentiator of asthma phenotype. Since viruses are the most common trigger in these children, viral-induced asthma is an appropriate diagnosis among these patients whose symptoms disappear completely between episodes and usually recur following a cold. The phenotype of exercise-induced asthma can also be observed in this age group.1 Tests for the presence of specific immunoglobin E (IgE) antibodies, such as skin prick or in vitro tests, should be performed to obtain information that may supplement clinical information regarding a relationship between exposure to a potential allergen and the occurrence of asthma symptoms. Findings of such antibodies are consistent with the phenotype of allergen-induced asthma. The Pediatric Consensus Report emphasized that atopy is a risk factor for the persistence of asthma, regardless of any observation that allergens are or are not obvious triggers of disease activity in an individual child. The absence of a specific allergic trigger may indicate a phenotype of nonallergic asthma. The clinician should consider this phenotype with caution, however, since the failure to identify an allergic trigger may reflect the fact that a specific allergic trigger was not detected.1 Among school-age children 6 to 12 years of age, the differentiators of asthma phenotypes are identical to those in younger children; however, the clinician should consider that cases of allergen-induced asthma are more common and visible in the older children, and seasonality may be a more evident factor. Finally, virus-induced asthma should also be considered in these children since it is still common.1

18. Manejo Control ambiental Farmacoterapia Inmunoterapia Educaci�n The Pediatric Consensus Report reinforced that management of asthma in children should be founded on a comprehensive treatment plan individualized to each specific patient�s needs.1 Whenever possible, avoidance measures should be instituted to reduce exposure of the patient to known allergens or irritant triggers.1 Pharmacotherapy should be initiated to achieve the goal of controlling symptoms and preventing asthma exacerbation, while minimizing the risk of drug-related adverse experiences.1 Pediatric patients, parents, and caregivers should receive education about asthma and its management. Primary care physicians, nurses, and allied health professionals who interact with children with asthma should also receive continuing medical education or continuing professional development regarding best clinical practice for asthma patients.1 Immunotherapy may also be beneficial in selected children with allergic asthma.1The Pediatric Consensus Report reinforced that management of asthma in children should be founded on a comprehensive treatment plan individualized to each specific patient�s needs.1 Whenever possible, avoidance measures should be instituted to reduce exposure of the patient to known allergens or irritant triggers.1 Pharmacotherapy should be initiated to achieve the goal of controlling symptoms and preventing asthma exacerbation, while minimizing the risk of drug-related adverse experiences.1 Pediatric patients, parents, and caregivers should receive education about asthma and its management. Primary care physicians, nurses, and allied health professionals who interact with children with asthma should also receive continuing medical education or continuing professional development regarding best clinical practice for asthma patients.1 Immunotherapy may also be beneficial in selected children with allergic asthma.1

19. RECOMENDACIONES Management of asthma in children generally involves avoidance measures against airborne allergens and irritant triggers, whenever possible.1 Such measures are recommended in the Pediatric Consensus Report when the patient has become sensitized to an allergen and there is clear evidence of an association between allergen exposure and the emergence of asthma symptoms.1 It should be noted, however, that clinically relevant results may require thorough allergen avoidance, which may be difficult to achieve and sustain in daily life.1 Allergen testing is recommended at all ages for children who have asthma.1 These patients should also avoid exposure to asthma triggers, such as cigarette smoke, which should be eliminated from the environment of children with a history of wheezing and, ideally, of all children, according to the consensus report.1 To avoid comorbid obesity, children with asthma should be encouraged to consume balanced diets.1 Finally, children with asthma should not avoid exercise and should be encouraged to participate in sports while controlling asthma inflammation and symptoms.1 Management of asthma in children generally involves avoidance measures against airborne allergens and irritant triggers, whenever possible.1 Such measures are recommended in the Pediatric Consensus Report when the patient has become sensitized to an allergen and there is clear evidence of an association between allergen exposure and the emergence of asthma symptoms.1 It should be noted, however, that clinically relevant results may require thorough allergen avoidance, which may be difficult to achieve and sustain in daily life.1 Allergen testing is recommended at all ages for children who have asthma.1 These patients should also avoid exposure to asthma triggers, such as cigarette smoke, which should be eliminated from the environment of children with a history of wheezing and, ideally, of all children, according to the consensus report.1 To avoid comorbid obesity, children with asthma should be encouraged to consume balanced diets.1 Finally, children with asthma should not avoid exercise and should be encouraged to participate in sports while controlling asthma inflammation and symptoms.1

20. Personas Afectadas Paciente Padres Cuidadores Profesionales de la Salud M�dicos Generales Enfermeras Farmace�ticos Trabajadores de la salud y grupos de apoyo a pacientes Autoridades de Salud y Pol�ticos PRACTALL Educaci�n The Pediatric Consensus Report stresses that education about asthma is an integral component of disease management in children with asthma.1 For pediatric patients, their parents, and other caregivers who are directly affected by the child�s asthma, education should increase knowledge of this disease, allay fears or preconceptions about the disease or its management, and foster communication among patients, parents, and caregivers, and with health care professionals.1 At a minimum, asthma education of the child and parents entails face-to-face interaction with the treating physician and a review of the child�s treatment plan at each consultation. A 3-tiered educational program would then be implemented in a manner appropriate for the child�s disease severity, stage of development, and need for information.1 Such a program would start with education for the patient and at least 1 parent about the nature of asthma, its causes and triggers, and the need to take daily medications in moderate and severe asthma even when the child does not feel symptoms.1 Children with moderate or severe asthma and their parents should receive intensive education regarding the consequences of severe asthma and nonadherence to medication.1 Finally, other caregivers should be informed of the child�s asthma.1 The consensus report also includes an array of health care professionals in its recommendations for asthma education. Primary care physicians should be able to recognize and treat asthma, as well as acute asthma attacks, according to local guidelines. These physicians should understand when to refer a child with asthma to a specialist.1 Nurses who work with children need to know how to advise on asthma, and specialist asthma nurses can help educate other allied health care professionals.1 Pharmacists, health-education workers, and patient support groups should also be involved in educational efforts regarding pediatric asthma.1 Finally, the consensus report advises that educating health authorities and politicians can help ensure prioritization of this disease in discussions of medical issues and facilitate adequate levels of organization and provision of care.1The Pediatric Consensus Report stresses that education about asthma is an integral component of disease management in children with asthma.1 For pediatric patients, their parents, and other caregivers who are directly affected by the child�s asthma, education should increase knowledge of this disease, allay fears or preconceptions about the disease or its management, and foster communication among patients, parents, and caregivers, and with health care professionals.1 At a minimum, asthma education of the child and parents entails face-to-face interaction with the treating physician and a review of the child�s treatment plan at each consultation. A 3-tiered educational program would then be implemented in a manner appropriate for the child�s disease severity, stage of development, and need for information.1 Such a program would start with education for the patient and at least 1 parent about the nature of asthma, its causes and triggers, and the need to take daily medications in moderate and severe asthma even when the child does not feel symptoms.1 Children with moderate or severe asthma and their parents should receive intensive education regarding the consequences of severe asthma and nonadherence to medication.1 Finally, other caregivers should be informed of the child�s asthma.1 The consensus report also includes an array of health care professionals in its recommendations for asthma education. Primary care physicians should be able to recognize and treat asthma, as well as acute asthma attacks, according to local guidelines. These physicians should understand when to refer a child with asthma to a specialist.1 Nurses who work with children need to know how to advise on asthma, and specialist asthma nurses can help educate other allied health care professionals.1 Pharmacists, health-education workers, and patient support groups should also be involved in educational efforts regarding pediatric asthma.1 Finally, the consensus report advises that educating health authorities and politicians can help ensure prioritization of this disease in discussions of medical issues and facilitate adequate levels of organization and provision of care.1

21. PRACTALL Conclusiones Identificar el fenotipo de asma. El manejo incluye control ambiental y educaci�n. Tratamiento de la inflamaci�n de la v�a a�rea que conlleve al control �ptimo. CSI y LTRAs est�n recomendados como terapia controladora inicial. Hasta que tengamos disponible nueva evidencia de la efectividad y seguridad a largo plazo, los bAAP no deben ser utilizados sin CSI. La Inmunoterapia en conjunto con el control ambiental y farmacoterapia. In summary, the Pediatric Consensus Report provides specific recommendations for management of asthma in childhood. Fundamentally, comprehensive asthma management in children must feature avoidance measures, pharmacotherapy, and education. Identification of asthma phenotype should be attempted, including evaluation of atopic status.1 Because asthma symptoms most often occur in the setting of inflammation, the guidelines recommend that the main goal of controller therapy should be to reduce bronchial inflammation. In fact, treatment of airway inflammation is needed to achieve optimal asthma control. ICS and LTRAs are recommended first-line treatments for persistent asthma. LTRAs are also recommended first-line treatment in mild asthma. LABAs should not be used without an appropriate dose of ICS until further evidence of effectiveness and long-term safety becomes available.1 Immunotherapy may be appropriate for selected patients.1 In summary, the Pediatric Consensus Report provides specific recommendations for management of asthma in childhood. Fundamentally, comprehensive asthma management in children must feature avoidance measures, pharmacotherapy, and education. Identification of asthma phenotype should be attempted, including evaluation of atopic status.1 Because asthma symptoms most often occur in the setting of inflammation, the guidelines recommend that the main goal of controller therapy should be to reduce bronchial inflammation. In fact, treatment of airway inflammation is needed to achieve optimal asthma control. ICS and LTRAs are recommended first-line treatments for persistent asthma. LTRAs are also recommended first-line treatment in mild asthma. LABAs should not be used without an appropriate dose of ICS until further evidence of effectiveness and long-term safety becomes available.1 Immunotherapy may be appropriate for selected patients.1

22. POST PRACTALL Los objetivos principales del tratamiento del asma consisten en Alcanzar y mantener el control de los s�ntomas. Mantener actividades normales, incluso el ejercicio, Mantener la funci�n pulmonar lo m�s pr�ximo a lo normal Prevenir las exacerbaciones del asma. Evitar los efectos nocivos de los medicamentos. Prevenir la mortalidad por asma Gu�a de Pr�ctica Cl�nica Para el Diagn�stico y Tratamiento de Asma. Enero de 2008 Dr. Mart�n Becerril Angeles

23. POST PRACTALL Antileucotrienos Los antileucotrienos son una alternativa para pacientes con reacciones adversas por esteroides inhalados o incapaces de usarlos, y en aquellos con rinitis al�rgica asociada En los menores de 5 a�os con asma intermitente los antileucotrienos pueden disminuir las crisis asm�ticas inducidas por virus En ni�os mayores de 5 a�os con esteroides inhalados en dosis bajas y asma mal controlada agregar antileucotrienos produce una mejor�a cl�nica moderada y reduce las exacerbaciones Gu�a de Pr�ctica Cl�nica Para el Diagn�stico y Tratamiento de Asma. Enero de 2008 Dr. Mart�n Becerril Angeles

24. POST PRACTALL Varios meta-an�lisis han demostrado que la adici�n de un LABA es m�s efectiva que aumentar la dosis de los ICS, en cuanto a la mejor�a en el control del asma y reducci�n en exacerbaciones. Los pacientes que recibieron tratamiemto combinado utilizaron poca medicacion de rescate y tuvieron mayor adherencia En el caso ICS como monoterapia, la reducci�n de dosis puede resultar en p�rdida del control del asma Adicionar salmeterol mejora la sintomatolog�a, pero a expensas de incrementar los riesgos de presentar eventos adversos medicamentosos. John Oppenheimer y Harold S. Nelson, Seguridad de los �-agonistas de larga duraci�n en el asma: una revisi�n Curr Opin Pulm Med 2008, 14:64-69 Delea TE, et al. Effects of fluticasone propionate/salmeterol combination on asthma-related health care resource utilization and costs and adherence in children and adults with asthma. Clin Ther. 2008 Mar;30(3):560-71. Cates C, Cates M "Regular treatment with salmeterol for chronic asthma: serious adverse events" Cochrane Database of Systematic Reviews 2008

25. GINA 2009 En menores de 4 a�os se propone inhalador presurizado de ICS con dosis medida, con espaciador con mascarilla. En los mayores de 4 a�os se prefiere el espaciador con boquilla En caso de decidirse por la presentaci�n nebulizada se prefiere hacerlo con mascarilla Global Strategy for the Diagnosis and Management of Asthma in Children 5 years and Youngers 2009

26. GINA 2009 Pr�cticamente no hay estudios en menores de 4 a�os El tratamiento NUNCA por menos de tres (3) meses Global Strategy for the Diagnosis and Management of Asthma in Children 5 years and Youngers 2009

27. GINA 2009 De no lograrse el control con esteroides inhalados se doblar� la dosis del esteroide, aunque otra opci�n es adicionar antileucotrienos Pobre control obliga a considerar otros diagn�sticos o el empleo de teofilinas o de esteroides orales Descontrol har� pensar en virus o en alergia respiratoria Global Strategy for the Diagnosis and Management of Asthma in Children 5 years and Youngers 2009

28. GINA 2009 Agitaci�n, astenia y confusi�n durante una exacerbaci�n har�n pensar en hipoxemia La severidad se manifiesta como taquicardia, cianosis o marcada hipoventilaci�n Global Strategy for the Diagnosis and Management of Asthma in Children 5 years and Youngers 2009

29. GINA 2009 Se considera de dif�cil control y requiere manejo hospitalario la falta de respuesta a tres dosis de un rescatador, taquipnea sin respuesta al broncodilatador, disnea continua, cianosis, tiraje y/o desaturaci�n por debajo de 92% Global Strategy for the Diagnosis and Management of Asthma in Children 5 years and Youngers 2009

30. GINA 2009 El asma de dif�cil control se maneja con oxigenoterapia, beta dos agonista de acci�n r�pida como rescatador, ipratropio, esteroides sist�micos y aminofilina Preferentemente en UCI Global Strategy for the Diagnosis and Management of Asthma in Children 5 years and Youngers 2009

31. ATS 2009 La inflamaci�n se incrementa por infecci�n viral (cl�nica o latente) y eso produce resistencia a los esteroides La inflamaci�n explica la exacerbaci�n y la remodelaci�n. El tabaquismo pasivo incrementa la respuesta inflamatoria E. Bel 170509

32. ATS 2009 Existe un mecanismo molecular complejo en la presencia del asma, sin saber si cada fenotipo tiene un mecanismo diferente y sin saber si esto se asocia con la manifestaci�n cl�nica de la enfermedad En todos los casos hay respuesta a los broncodilatadores P. WOODRUFF 170509

33. ATS 2009 La diferencia celular de los diferentes fenotipos parece localizarse en eosinofilos y neutrofilos No eosinofilos= resistencia a esteroides Eosinofilos= mayor riesgo a casos severos I. PAVORD 170509

34. 2009 6.5 millones de ni�os son atendidos cada a�o en los Estados Unidos. Con exacerbaciones intermitentes el resto de su vida, la raz�n es la falta de adherencia al esquema prescrito. A un grupo de asm�ticos leves se les manej� con monoterapia y a los que ten�an asma moderada se les incluy� un esquema con dos f�rmacos durante 12 meses. A los 4 meses se hizo una revisi�n para verificar el cumplimiento del esquema. De los que estaban con monoterapia solo el 60% estaba cumpliendo, el 59% de los que recib�an montelukast y el 38% de quienes recib�an esteroide inhalado. En los que recib�an combinaciones las cifras fueron similares, siempre predominando la adherencia en quienes recib�an montelukast (entre 30 y 50% mayor adherencia). La diferencia fue la comodidad de la v�a oral. Se genero una intervenci�n educativa, sin embargo los resultados no cambiaron y los ni�os sin montelukast fueron abandonando el tratamiento. Al final del estudio, la frecuencia de cumplimiento fue mayor a la v�a oral que a la inhalada, en asma leve 69% para la v�a oral y 31% para la inhalada, en los casos moderados: 55% cuando inclu�a v�a oral y 41% para la exclusivamente inhalada. Fitzpatrick AM et al, Measuring Medication Adherence Among Children With Asthma J Pediatr Nurs. 2009;24:81-89

35. 2009 La gen�tica interviene en el desarrollo de asma, se han identificado m�ltiples genes involucrados, los llamamos genes con interacci�n ambiental. La infecci�n viral es el principal desencadenante y predominan Rinovirus y virus sincicial respiratorio. El 80% sucede antes de los 5 a�os de edad. La causa m�s com�n de su cronicidad es la rinitis al�rgica, otro grupo lo asocia con el ejercicio. Significan una clara interacci�n entre los genes, los virus, la alergia domiciliaria y el ejercicio f�sico. Cada vez hay mayor informaci�n asociando el asma con el acetaminofen, el tabaco y los niveles bajos de vitamina D. El 60% de los ni�os tendr�n un broncoespasmo, pero el 15% tendr� asma. Existe una tabla con criterios: si un chico tiene 1 criterio mayor o 2 menores, tiene un 75% de posibilidad de desarrollar asma. Como criterio mayor se considera la presencia de eczema; la historia familiar de asma o la evidencia de alergia al polvo casero al polen o a la caspa de perros y gatos. Los criterios menores son sibilancias con los resfr�os, rinitis al�rgica y sensibilidad a la prote�na del huevo, leche o cacahuates. Los medicamentos que usamos no han demostrado que modifiquen la historia natural de la enfermedad. Bradley E. Chipps, MD, Recent Advances in Childhood Asthma: An Expert Interview Medscape: 24 Aug 2009

36. GRACIAS POR NO FUMAR hector.velarde@imss.gob.mx dr_velarde@yahoo.com