1 / 42

Asthma in childhood

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.

yestin
Télécharger la présentation

Asthma in childhood

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Asthma in childhood E. Picard M.D. Pediatric Pulmonary Unit Shaare Zedek Medical Center Jerusalem

  2. ASTHMA: DEFINITION Asthma is a chronic inflammatory disease of the airways characterized by reversible obstruction of airflow

  3. Asthma: inflammation Normal Asthma

  4. Epithelial damage in Asthma CILIA Epithelium Normal Asthmatic

  5. Bronchus- סמפון • אצל חולה אסטמה • מצב תקין

  6. 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.

  7. 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

  8. 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 כ8%(בנים 8.6% בנות 6.9%) [CHEST 2007] שכיחות המחלה גבוהה יותר במדינות מתועשות (ניו זילנד 30%, טיבט 0.8%) מאשר במדינות המתפתחות

  9. שכיחות האסתמה והתמותה Source 1: GINA– Global strategy for asthma management and prevention 2006 – chapter 1

  10. Epidemiology • עישון בזמן הריון ואחרי הלידה הם גורמי סיכון להתפתחות של אסטמה אצל ילדים Slide 1

  11. אסטמה: קליניקה • שיעול: אינטרמיטנתי, יבש, לילי (אחרי חצות), לאחר מאמץ או היפרוונטילציה (צחוק) • דיספנאה וטכיפנאה • לחץ בחזה

  12. אנמנזה: אלרגיות? • מעל שני שליש של חולים אסטמטים יש סיפור של אלרגיות • האם יש ריניטיס אלרגית ? (נזלת שקופה עונתית)

  13. Asthma-Diagnosis: History • Most Asthmatic Patients have Allergic Rhinitis (children 80-90%, adults 50%) Allergic rhinitisalone Allergicrhinitis +asthma Asthmaalone Leynaert B et al Am J Respir Crit Care Med 2000;162:1391-1396 SGA 2001-W-6472-SS

  14. אנמנזה: אלרגיות? Atopic dermatitis (cheeks and extensor surfaces )

  15. בדיקה פיזיקאלית: האזנה • צפצופים אקספירטורים בעיקר • אקספריום מאורך (יותר מאינספריום)

  16. בדיקה פיזיקאלית • clubbing very rare !!!!!.

  17. אסטמה בדיקות מעבדה • Eosinophilia, High level of IgE • Skin tests(weal-flare reaction, diameter of the weal !!)

  18. אסטמה: צילום חזה • כדאי לבצע צילום חזה, יותר כדי לשלול פתולוגיה אחרת • צילום חזה באסטמה: תקין / היפראינפלציה / עיבוי פריברונכיאלי / תמטים

  19. צילום חזה

  20. Asthma-Diagnosis:Lung-Tests • Lung function tests: PEF, FVC, FEV1, FEV1/FVC, FEF 50%.

  21. Asthma: Diagnosis Obstructive pattern

  22. Asthma-Diagnosis:Lung-Tests Improvement of more than 12% of FEV1 to beta 2 agonists

  23. Asthma: Diagnosis • Bronchial Challenge Test: Methacholine, Adenosine, Exercise (worsening of FEV1 >10-15%)

  24. אסטמה ילדים: אבחנה מבדלת זיהום בסמפונות הראה הגורם להיצרות שלהם “Acute bronchitis/ bronchiolitis”

  25. 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)

  26. 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…

  27. Bronchiolitisclinical 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

  28. Bronchiolitisclinical signs • Critical phase 48-72 hours • RSV shed from respiratory tract until 9 days, survive on hands (Isolation, hand washing!!!)

  29. Bronchiolitislaboratory • WBC within normal limits • X-ray: Diffuse hyperinflation with flattening of diaphragms, atelectasis. • Diagnostic: Ag detection by immunofluorescent on nasal secretions.

  30. Bronchiolitis

  31. BronchiolitisTreatment (1) • Humidified oxygen, (Helium) • Bronchodilators: Salbutamol small improvement in clinical score but do not reduce hospital admission (Cochrane 2010)

  32. BronchiolitisTreatment (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.

  33. Bronchiolitis treatment: Hypertonic saline • Inhaled 3–9% HS has proved a useful tool in several respiratory diseases (mainly CF) Pezzulo BMJ 2012. סליין היפרטוני: 1)מגדיל את גובה הנוזל המצפה את דפנות דרכי האוויר (airways surface liquid=ASL ) מוריד צמיגות 2)מקטין את הבצקת בשכבה התת-רירית 3) מאיץ את קצב פנוי הליחה

  34. BronchiolitisTreatment (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.

  35. Bronchiolitispreventivetreatment • 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

  36. Bronchiolitispreventivetreatment (indication according to ministry of health) • BPD: BPD with oxygen until age of 2, BPD until age of 1 even without oxygen • Premature baby: < 31 (+6d) weeks and younger than 1 year • Birth weight < 1 kg: younger than 1 year • Chronic pulmonary disease: younger than 1 year (on O2, on steroids PO, active CF, Down with rec pneumonia, s/p TE fist repair, BO ..) • CHD with CHF on treatment until age of 1 y • Cyanotic heart disease until age of 1 • PHT moderate to severe until age of 1.

  37. 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 Asthma in infancy: prognostic factors Transient 20% Never Wheezed 51% Persistent 14% Late 15% Martinez et al. NEJM 1995;332: 133-8

  38. 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

  39. 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

  40. Asthma Treatment • Acute asthma • Chronic asthma

  41. Acute asthma treatment • Oxygen as needed • b2agonists: 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)

  42. The end

More Related