Transcript Slide 1

Asthma in childhood
E. Picard M.D.
Pediatric Pulmonary Unit
Shaare Zedek Medical Center
Jerusalem
ASTHMA: DEFINITION
Asthma is a chronic
inflammatory disease of the
airways characterized by
reversible obstruction of
airflow
Asthma: inflammation
Normal
Asthma
Epithelial damage in Asthma
CILIA
Epithelium
Normal
Asthmatic
‫סמפון ‪Bronchus-‬‬
‫מצב תקין •‬
‫אצל חולה אסטמה •‬
Asthma: Pathophysiology
• Allergens inhaled
presented to T and B
cells
• Interaction among
these cells and by
influence of IL4 and
IL13, switch of B
cells to synthesize
IGE
• Then IGE bind to IGE
receptor of mast
cells and the early
and late response
occur.
Asthma: Pathophysiology
Late-response: (4-6 hours
later):
 mediators (IL5) activate
eosinophils and other
inflammatory cells which
migrate to the airways.
 Release of inflammatory
mediators (major basic
protein, eosinophilic cationic
protein, leukotrienes, …)
which cause epithelial cell
damage, airway edema, mucus
hypersecretion etc...
 The Result: Airway
inflammation
‫שכיחות מחלת האסטמה בילדים‬
‫‪ ‬מחלה הכרונית הכי שכיחה בילדים‬
‫‪ ‬סיבה הכי שכיחה של ביקורים בחדר מיון ילדים‬
‫‪ ‬שכיחות האסטמה גבוהה יותר בילדים מאשר במבוגרים‬
‫‪ ‬אצל ילדים יותר בנים מאשר בנות ולהפך אצל מבוגרים‬
‫‪ ‬בארץ שכיחות במתבגרים כ‪( 8%‬בנים ‪ 8.6%‬בנות ‪)6.9%‬‬
‫[‪]2007 CHEST‬‬
‫‪ ‬שכיחות המחלה גבוהה יותר במדינות מתועשות‬
‫‪ ,30%‬טיבט ‪ )0.8%‬מאשר במדינות המתפתחות‬
‫(ניו זילנד‬
‫שכיחות האסתמה והתמותה‬
Source 1: GINA– Global strategy for asthma management and prevention 2006 – chapter 1
‫‪Epidemiology‬‬
‫‪ ‬עישון בזמן הריון ואחרי הלידה הם גורמי סיכון להתפתחות של‬
‫אסטמה אצל ילדים‬
‫‪Slide 1‬‬
‫אסטמה‪ :‬קליניקה‬
‫‪ ‬שיעול‪ :‬אינטרמיטנתי‪ ,‬יבש‪ ,‬לילי‬
‫(אחרי חצות)‪ ,‬לאחר מאמץ או‬
‫היפרוונטילציה (צחוק)‬
‫‪ ‬דיספנאה וטכיפנאה‬
‫‪ ‬לחץ בחזה‬
‫אנמנזה‪ :‬אלרגיות?‬
‫‪ ‬מעל שני שליש של חולים אסטמטים יש סיפור של‬
‫אלרגיות‬
‫‪ ‬האם יש ריניטיס אלרגית ? (נזלת שקופה עונתית)‬
Asthma-Diagnosis: History
Allergic rhinitis
alone
Allergic
rhinitis + asthma
Asthma
alone
• Most Asthmatic Patients have Allergic Rhinitis (children 8090%, adults 50%)
SGA 2001-W-6472-SS
Leynaert B et al Am J Respir Crit Care Med 2000;162:1391-1396
?‫ אלרגיות‬:‫אנמנזה‬
Atopic dermatitis (cheeks and extensor
surfaces )
‫בדיקה פיזיקאלית‪ :‬האזנה‬
‫‪ ‬צפצופים אקספירטורים בעיקר‬
‫‪ ‬אקספריום מאורך (יותר מאינספריום)‬
‫בדיקה פיזיקאלית‬
• clubbing very rare !!!!!.
‫אסטמה בדיקות מעבדה‬
 Eosinophilia, High level of IgE
 Skin tests
(weal-flare reaction, diameter of the weal !!)
‫אסטמה‪ :‬צילום חזה‬
‫• כדאי לבצע צילום חזה‪ ,‬יותר כדי לשלול פתולוגיה אחרת‬
‫• צילום חזה באסטמה‪ :‬תקין ‪ /‬היפראינפלציה ‪ /‬עיבוי‬
‫פריברונכיאלי ‪ /‬תמטים‬
‫צילום חזה‬
Asthma-Diagnosis: Lung-Tests
Lung
function
tests: PEF,
FVC, FEV1,
FEV1/FVC,
FEF 50%.
Asthma: Diagnosis
Obstructive pattern
Asthma-Diagnosis: Lung-Tests
Improvement of more than 12% of FEV1 to
beta 2 agonists
Asthma: Diagnosis
• Bronchial Challenge Test: Methacholine,
Adenosine, Exercise (worsening of FEV1 >10-15%)
‫אסטמה ילדים‪ :‬אבחנה מבדלת‬
‫זיהום בסמפונות הראה הגורם להיצרות שלהם‬
‫”‪“Acute bronchitis/ bronchiolitis‬‬
Bronchiolitis
• Etiology: RSV (respiratory
syncytial virus)
• Invasion of bronchioles by virus:
edema and accumulation of
mucus, obstruction of airways.
• Common disease of infancy (<6
months) Leading cause of
hospitalization for infants
• Adult infected are also
symptomatic: (simple cold)
Acute Bronchiolitis
• High incidence in winter (January /
February) around 13 weeks..
• More severe disease: Male, age < 6
months, no breast feeding, tobacco
exposure
• High risk population:
→Age (1-3 months), C.H.D., Premature
babies, C.L.D., Trisomy-21…
Bronchiolitis clinical signs
• First 1-2 days symptoms of viral disease
(slight fever, rhinorrhea…)
• Gradual development of respiratory
distress
• Apneic spells in infants (hypoxia?, CNS
toxins?, U.A.O.?)
• Rhonchi, crackles or wheezes in
auscultation
Bronchiolitis clinical signs
• Critical phase 48-72 hours
• RSV shed from respiratory tract until 9
days, survive on hands (Isolation, hand
washing!!!)
Bronchiolitis laboratory
• WBC within normal limits
• X-ray: Diffuse hyperinflation with
flattening of diaphragms, atelectasis.
• Diagnostic: Ag detection by
immunofluorescent on nasal secretions.
Bronchiolitis
Bronchiolitis Treatment (1)
Humidified oxygen,
(Helium)
Bronchodilators:
Salbutamol small
improvement in clinical
score but do not reduce
hospital admission
(Cochrane 2010)
Bronchiolitis Treatment (2)
Adrenaline:
Adrenaline by inhalations seems better than Salbutamol
(Menon J of Ped 1995, Bertrand Ped pulm 2001)
Adrenaline vs placebo no difference between 2 groups
(Wainwright NEJM 2003)
Cochrane 2011: Nebulised epinephrine short-term
improvement in outpatients . No evidence of
effectiveness for repeated dose or prolonged use of
epinephrine among inpatients.
Corticosteroids inhaled or systemic:
Cochrane 2013: Current evidence does not support a
clinically relevant effect of systemic or inhaled
glucocorticoids on admissions or length of
hospitalisation.
Bronchiolitis treatment:
Hypertonic saline
• Inhaled 3–9% HS has proved a useful tool in several
respiratory diseases (mainly CF) Pezzulo BMJ 2012.
:‫סליין היפרטוני‬
airways ( ‫)מגדיל את גובה הנוזל המצפה את דפנות דרכי האוויר‬1
‫ ) מוריד צמיגות‬surface liquid=ASL
‫רירית‬-‫)מקטין את הבצקת בשכבה התת‬2
‫) מאיץ את קצב פנוי הליחה‬3
Bronchiolitis Treatment (3)
 Hypertonic saline 3% and terbutaline > N.S
and terbutaline in bronchiolitis and HS 3% >
NS (Sarrell chest 2002) and (Kuzik J Pediatr 2007)
 Nebulization with 5% hypertonic saline is
safe and efficient in bronchioilitis (Al Ansari
J Pediatr 2010)
 Cochrane 2013: Current evidence suggests
that in bronchiolitis nebulised 3% saline may
significantly reduce the length of hospital
stay bronchiolitis and improve the clinical
severity score.
Bronchiolitis preventive treatment
Standard IGIV no effective
RSV vaccine not successful
PALIVIZUMAB (synagis) Monoclonal
Antibody:
IM once a month in the winter (11 to 03)
reduces hospitalizations and decreases
severity
Bronchiolitis preventive treatment
(indication according to ministry of health)
1) BPD: BPD with oxygen until age of 2,
BPD until age of 1 even without oxygen
2) Premature baby: < 31 (+6d) weeks and younger
than 1 year
3) Birth weight < 1 kg: younger than 1 year
4) Chronic pulmonary disease: younger than 1 year
(on O2, on steroids PO, active CF, Down with rec
pneumonia, s/p TE fist repair, BO ..)
5) CHD with CHF on treatment until age of 1 y
6) Cyanotic heart disease until age of 1
7) PHT moderate to severe until age of 1.
Asthma in infancy: prognostic
factors
Never
Wheezed
51%
Transient
20%
Late
15%
Persistent
14%
Never Wheezed (51%) by age of 6 y
Transient (20%) Wheeze <3 y No wheeze by 6 year
Persistent (14%): Wheeze <3y Wheeze at 6 year
Late (15%): no wheeze <3y Wheeze at 6 y
Martinez et al. NEJM 1995;332: 133-8
Asthma in infancy: prognostic
factors
Up to 50% of all infants below age of 6 will
have at least one episode of wheezing
60% of early wheezers (<3y) do not wheeze
at 6
10-70% (the truth around 50-60%) of
asthmatic children have resolution of the
condition by adulthood
Asthma in infancy: prognostic
factors
Severe disease
Age > 3 years
Allergic / atopic children (no viral
induced)
Tobacco smoke exposure
Familial history (25% to 50% if one or
two parents asthmatics
Asthma Treatment
 Acute asthma
 Chronic asthma
Acute asthma treatment
 Oxygen as needed
b2 agonists: each 20 minutes
 Corticosteroids: I.V. (1-4mg/kg/d)
Consider Aerovent, Aminophylline I.V.,
Mg SO4.
Helium (low density, ↓ Reynolds number
more laminar flow)
The end