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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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