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

Tsai, JACI 2012;129:1252

1.813.000 visits for acute asthma from 470 ED1.144 asthma-related deaths

Asthma mortality in children appears to occur more often in the out-of-hospital setting

37

204

903

167 annual asthma-related deaths among children in the US

Fatal and near-fatal asthma in children

Newth, J Pediatr 2012;161:214

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%

33% 32%

Pediatric asthma death: the mild are at risk

Analysis of 51 deaths due to asthma

Robertson, Pediatr Pulmonol 1992;13:95

Only 18/51 children had spirometry in the previous year

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

In un’occasione, la ragazza giunge in PS conrespiro 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

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

Normal inspiration Inspiration with paradoxical vocal cord adduction

Vocal cord dysfunction

Dysfunctional breathing

Normal SaO2 !

Hyperventilation syndrome in adolescents with and without asthma

D’Alba, Pediatr Pulmonol 2015, online

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

Clinical features of vocal cord dysfunction

Newman, AJRCCM 1995;152:1352

95 hospitalized patients in whom VCD was diagnosedPredominantly young women

Acute asthma: Memorandum

Is it asthma?

Assessment of severity

Treatment

When to admit

When to discharge

When all think alike, no one thinks very much

Acute asthma: Memorandum

Is it asthma?

Assessment of severity

Treatment

When to admit

When to discharge

Assessment of severity

His

tory

Functional evaluation

Physical exam

ination

FAST

• 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

Acute asthma: 1- History

Predisposing factors to severe attacks

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

Valutazione di gravità dell’asma acuto

La presenza di diversi parametri, ma non necessariamente tutti,

indica la gravità dell’esacerbazione

Acute asthma: Memorandum

Is it asthma?

Assessment of severity

Treatment

When to admit

When to discharge

Correct hypoxia

Relieve bronchoconstriction

Reduce inflammation

Maintain hydro-electrolyte balance

Acute asthma: initial treatment

Correct hypoxia - Oxygen

Relieve bronchoconstriction

Reduce inflammation

Maintain hydro-electrolyte balance

Acute asthma: initial treatment

Acute asthma: Oxygen

The Venturi mask:

• Easy to apply

• Allows for constant FIO2 irrespective of the pattern of breathing

• FIO2 concentrations from 24% up to 50-60%

All episodes except for mildPreferably by maskTarget SaO2 >92%

Correct hypoxia - Oxygen

Relieve bronchoconstriction- Short-acting beta2-

agonists

Reduce inflammation

Maintain hydro-electrolyte balance

Acute asthma: initial treatment

Nebulized salbutamol in acute asthma: importance of the dose and the frequency of the doses

0.05 mg/kg/20 min >0.15 mg/kg/hour

0.15 mg/kg/20 min > 0.05 mg/kg/20 min

0.3 mg/kg/hour continuous >0.3 mg/kg/hour intermittent

Robertson, J Pediatr 1985

Schuh, Pediatrics 1989

Papo, Crit Care Med 1993

Frequent intermittent or continuous nebulization of

salbutamol is the most effective treatment

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

Holding chambers versus nebulisers for beta-agonists treatment of acute asthma

Cates, Cochrane 2013

25 RCT – 1897 children 2-17 yrs

• Salbutamol is the basic drug

• Efficacy proved in all ages

• By inhalation route – Fast onset of action

• Single dose = 0.15 mg/Kg by nebulization

= 100 mcg/5 kg by MDI+spacer

• Repeated intermittent doses should be administered

• Frequency of administration is related to severity

• Nebulizer vs MDI+spacer: same efficacy

Asthma: Short-acting beta2-agonists

Correct hypoxia - Oxygen

Relieve bronchoconstriction- Short-acting beta2-agonists- Anticholinergics

Reduce inflammation

Maintain hydro-electrolyte balance

Acute asthma: initial treatment

Adding ipratropium to salbutamol in acute asthma: importance of the dose and the frequency of doses

SLB 0.05 mg/kg/20 min ± IPR 250 mcg single dose

SLB 0.05 mg/kg/20 min ± IPR 250 mcg/20 min

Beck, J Pediat 1985

Reisman, JACI 1988

Schuh, J Pediatr 1995

SLB 0.15 mg/kg/20 min ± IPR 250 mcg/20 min

Adding ipratropium to salbutamol was always more effective than

using salbutamol alone

SLB 0.15 mg/kg/20 min + IPR 250 mcg/20 min

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.

Anticholinergics in acute asthma: a metanalysis

Rodrigo, Thorax 2005;60:740Griffiths, Cochrane 2013Vezina, Cochrane 2014

ED: 20 RCT, 2697 children 1-18 yrsHospitalized: 4 RCT, 472 children 1-18 yrs

• 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

Asthma: Anticholinergics

Correct hypoxia - Oxygen

Relieve bronchoconstriction- Short-acting beta2-agonists

- Anticholinergics

Reduce inflammation- Steroids

Maintain hydro-electrolyte balance

Acute asthma: initial treatment

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

• 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

Acute asthma: Systemic steroids

de Benedictis, AJRCCM 2012;185:12

Effect of systemic steroids in acute asthma: a question of time

Bhogal, Curr Opin Pulm Med 2013;19:73

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 vs Prednisone 2 mg/kg

added to standard therapy in EDIf discharge after 4 h: Fluticasone 500 mcg bid vs Prednisone 1 mg/kg, 7 days

Schuh, NEJM 2000;343:689

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 vs Prednisone 2 mg/kg in EDIn addition to standard therapy

If discharge after 4 h: Fluticasone 500 mcg bid vs Prednisone 1 mg/kg, 7 days

Schuh, Pediatrics 2006;118:244

Relapse rate by 48 hours

Fluticasone 12.5%

Prednisone 0%

Budesonide nebulization added to systemic prednisolone in acute asthma in children

906 children aged 2-12 years with moderate or severe acute asthma in EDAddition of budesonide 500 mcg/dose vs placebo to standard treatment

(salbutamol + ipratropium (3 doses) + prednisolone 2 mg/kg)

Alangari, Chest 2014;145:772

p=0.03

% p=0.03

Admission rate Change of asthma score from baseline

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

Acute asthma: initial treatment

How to manage the patient which does not improve

after standard treatment?

Improve bronchodilation- Theophylline- Beta2 agonists (iv)- Epinephrine- Magnesium sulphate- Anesthetics

Reduce respiratory work load- Heliox

Mechanical ventilation

Acute asthma: subsequent treatment

Intravenous aminophylline in acute asthma in children:is there a role?

- Lung function Di Giulio, J Pediatr 1993;122:464

Carter, J Pediatr 1993;122:470

- Rapidity of clinical improvement Needleman, Arch Ped Adol Med

1996;149:206

- Clinical severity score Nuhoglu, Ann All Asth Immunol 1998;80:395

- Length of hospital stay Strauss, Pediatrics 1994;93:205

- More frequent adverse events

When added to standard therapy, no significant effect vs placebo on:

Our update is consistent with the original conclusions that the risk-benefit balance of intravenous aminophylline is unfavourable

Nair, Cochrane 2012

- Shorter recovery time

- Earlier discharge from ED

- Improved pulmonary function

- No advantage in length of stay in PICUBogie, Pediatr Emerg Care 2007:23:355

- Higher proportion of tremor Browne, Lancet 1997;349:301

Addition of intravenous to inhaled beta2-agonists for (severe) acute asthma in children

Travers, Cochrane 2012

2 RCT - 56 children

Intravenous magnesium sulfate in acute asthma in children: a meta-

analysis

5 RCT – 182 children

Cheuk, Arch Dis Child 2005;90:74

Odd ratio for hospitalization

Nebulized magnesium sulphatein 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

Powell, Lancet Respir Med 2013;1:301

Primary outcomeASS at 60 min post-treatment: statistically lower in the MgSO4 group, but not clinically significant

Secondary outcomesNo difference between groups The effect of MgSO4 was larger in

children with more severe asthma

Helium/Oxygen-driven albuterol nebulization in the treatment of children with acute asthma

30 children aged 2-18 yrs in EDStandard treatment + either heliox or oxygen

for driving nebulization of bronchodilators

Kim, Pediatrics 2005;116:1127

Discharge33%

Discharge83%

Acute asthma: Memorandum

Is it asthma?

Assessment of severity

Treatment

When to admit

When to discharge

History of previous severe attacks

Respiratory failure

Severe grading (clinical, oxygenation, functional) especially after 1 hour of treatment

Complications (pneumothorax, atelectasis)

Experience (!!??)

Acute asthma: Criteria for admission

The decision to admit or discharge a patient should be made within 4 hours after presentation to the ED !

Acute asthma: Memorandum

Is it asthma?

Assessment of severity

Treatment

When to admit

When to discharge

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

Acute asthma: Criteria for discharge after hospitalization

Doctor, please, respect the following 5 steps:

1. Release proper, written instructions for therapy

2. Review education

3. Prescribe beta-2 agonists for at least 1 week

4. Prescribe inhaled (+/- oral) steroids

5. Plan a control in one week

Acute asthma: Before discharge a patient

The emergency room management of acute asthma at our institution fell below generally accepted standards

Lack of communication between academic units and the frontline may be responsible….

Acute asthma: observations regarding the management of a pediatric emergency room

Pediatrics 1989;83:507

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