Astmul bronsic la copil

Introducere
Cea mai frecventa afectiune cronica a copilului
Cel mai frecvent diagnostic la copii spitalizati
Duce la mai multe spitalizari decat oricare alta afectiune pediatrica
Cauza principala de asistenta medicala de urgenta
Cauza cea mai frecventa de absenteism scolar
Asociat cu rinita alergica si dermatita atopica

Date epidemiologice
Astmul si afectiunile cu wheezing sunt conditii heterogene dpv al:
- factori de risc
- varsta de debut
- fenotip clinic
- severitate
- raspuns la tratament
- evolutie clinica de durata
Severitatea si FP au o evolutie din copilarie pana la varsta adulta
Esecul tratamentului in astm: asigurare necorespunzatoare a ingrijirilor medicale
Programele educationale, ghidurile terapeutice au dat rezultate bune in med primara
Planuri terapeutice organizate, educatia pacientului duc la eficientizarea terapiilor in A

Caracteristici clinice
Subdiagnosticat si supradiagnosticat
A intermitent este de obicei o infectie virala care induce un fenotip particular la copilul prescolar
(apare la toate varstele)
A persistent caracterizat de absenta perioadelor fara simptome
A sezonier alergic limitat la sezoane ce corespund la alergeni inhalatori IgE specifici

Diagnosticul astmului
Simptome persistente/recurente/noi astmatice:
- cum sa confirmam dg
- cand consideram dg altenative
Dg de A nu are limite inferioare de varsta
- controverse de dg
- catalogarea ca bronsite, pneumonii (tratament inutil cu Ab)

Terminologie
A= caracterizat de hiperresponsivitate a CA la variati stimuli ce rezulta in onstructie aeriana care este
reversibila substantial fie spontan, fie ca rezultat al unui tratament
Obstructia CA este rezultatul :
- gradelor variate de bronhospasm
- inflamatiei

Diagnosticul A
Va fi luat in considerare cand exista simptome:
- wheezing recurent/cronic predominent in expir
- tuse recurenta/cronica
- diagnostic repetat de bronsita
- diagnostic repetat de pneumonie, inconsistent cu o cauza de infectie piogena
Confirmarea eficienta a dg se face prin:
- demonstrarea imbunatatirii simptomelor pe spirometrie dupa inhal beta2 agonist si cura scurta de CS
- lipsa de raspuns va determina nevoia altor investigatii
Istoricul natural al astmului
Majoritatea nu vor mai avea simptome pana la adolescenta
O majoritate vor avea simtome si la varsta adulta, chiar daca nu au avut in adolescenta
Copii care prezinta wheezing in afara infectiilor virale au o probabilitate mai mare de a avea simptome
si la varsta adulta

Caracteristicile clinice ale astmului: - Natura heterogena

Stabilirea dg de A nu e suficienta pt dezvoltarea unui plan terapeutic
Este necesara identificarea patternului clinic al bolii (fenotipuri)
Cum stabilim fenotipurle de astm la copil?
Care este varsta de debut a simpt CRI?
Simtomele de A sunt asociate NUMAI cu o inf respiratorie?
Exista perioade extinse intre episoade, fara tuse si wheezing?
Exista variatii sezoniere ale simpt?
Simptomele sezoniere sunt corelata cu sensibilizarea la alergenii inhalatori/IgE specifice?
Simptomele sunt corelate cu expunere la noxe?
Simptomele apra zilnic, pe perioade mai lungi?

Astmul intermitent
Simptome episodice
Triggerul principal : infectiile virale
De obicei apare in jurul varstei de 1-2 ani
Simptome specifice de IACS urmate de wheezing, respiratie dificila, IR
Durata simpt fara tratament: zile, sapt, luni
Intre episoade fara evidenta de inflamatie (BAL)
Distinctie intre fenomele virale si cele induse de alergeni
Lipsa sensibilizarii alergice: de bun augur pt disparitia in timp a simpt

Astmul persistent
Simptome zilnice tot anul, fara perioade liberein cazul lipsei tratamentului patogenic
Pot incepe ca forma intermitenta si continua cu simptome zilnice
Majoritatea au componenta alergica

Astmul alergic sezonier

Simptome zilnice in perioada sezonului alergic
Exista suprapuneri cu formele induse de infectii virale
Identificarea patternului clinic va duce la stabilirea startegiei terapeutice
Identificarea formelor induse de efort

Severitatea astmului
Interfera cu activitatea zilnica
Interfera cu somnul prin treziri nocturne
Frecventa masurilor terapeutice: bronhodil inh si CT orala

-Variatiile severitatii A
Simptomele interfera cu somnul?
Simptomele intrefera cu activitatile?
Care este frecventa folosirii medicatiei de urgenta (albuterol+CS sist)?
Care este frecventa consulturilor de urgenta?
Care este frecventa spitalizarilor?
Cat de des a fost necesara internarea in TI?
Care este nevoia de ventilatie asistata?
Au existat episoade amenintatoare de viata?
Tratament
Masuri interventionale pt simptomele acute:albuterol, CST orali
Tratament de intretinere pt cei cu boala cronica si sezoniera extinsa: CSTI, BDAL, MLT,
imunoterapie, anti IgE
Evaluarea si tratamentul astmului dificil
Distinctie intre aderenta scazuta si dg incorect
Tehnica inhalatorie
Educatia familiei
Spitalizare temporara
Monitorizarea evolutiei clinice
Sensibilizarea pacientului la simptomatologie pt prevenirea progresiei exacerbarilor
Vizite de urmarire programate
Educatie pacient, familie
Evaluarea aderentei si compliantei la tratament

Tratamentul acut
beta2 agonist inhalator, nebulizat/MDI
albuterol 2-4 inh, max 6 inh la 4-6 ore
Prednison 1-2mg/kg/la 12 ore , max 40mg/zi , methylprednisolone, dexamethasone
Ipratropium bromide 0.5mg nebulizat + albuterol (astm sever, acut, urgenta)

Tratamentul de intretinere
Corticoid inhalator
- budesonide 200mcg/zi doza minima-> max 800mcg sau echivalent
Montelukast 4,5, 10 mg/zi
LABA +ICS
Teofiline retard (> 12 ani)
Schimbare in ultimele decade de la: simptome :wheezing, tuse, respiratie scurtata, anatomie
patologica: bronchospasm. Edem, hipersecretie de mucus , modificari celulare, moleculare, inflamatie
eozinofile, mastocite, LTH2. descuamare celule epiteliale, remodelare

Prevalenta, istoric
variabila intre tari (5-15%), tari dezvoltate 8-10%
cea mai frecventa boala cronica a societatii vestice
dg incorect, intarziat - intarzie tratamentul
nu tot ce e wheezing e astm!
Exista tendinta de a trata simptomele ca rezultat al unui proces infectios (antibiotice, antitusive!)
- tusea = primul simptom al HRB!
- triggeri frecventi = infectii virale - asimpt, nu se aude obstructia
- inflamatie, remodelare!
- la multi copii simpt dispar/scad
Tratamentul corect previne exacerb, internari urgenta
Dg considerat:
mai mult de 1 episod wheezing
istoric familial de atopie/astm
alte manifestari alergice
debut de obicei < 2-3 ani - oportunitate de tratament antiinflamator
imbunatatirea FP
inflamatie netratata = remodelare
Remodelare:
-disruptia epiteliului
-depozitie colagen sub mb bazala
-hiperplazia glandelor mucoase
-vascularizatie crescuta
-proliferarea musc netede

Alte cauze de wheezing:

-FC
-bronsita/bronsiolita
-fistula traheo-bronsica
-atelectazie
-RGE
-mase mediastinale
-inele vasculare
-BCC

Diagnostic
istoric = anamneza detaliata, exclude alte afectiuni, include conditii ce pot inrautati astmul
-debut precoce
-episoade repetate de wheezing
-istoric alte boli alergice
-istoric al fenomenelor de atopie
simptome
usoare/severe
scurte/lungi ca durata
raspund/nu la terapie
precipitate de triggeri (infectii virale, exercitiu,alergeni alim/inh,poluare)
evolutie accent (noaptea,dupa amiaza, la effort/plans = HRB!)
Examenul fizic
in afara exacerbarilor - auscultatia = 0
wheezingul se aude numai cand hiperventileaza
multi nu au hipersecretie de mucus/nu tusesc
cand se aude - intermitent, sunete muzicale
cel mai sigur semn = afectarea altor organe
facies atopic
conjunctive hiperemice
nas cu prurit
respiratie orala
stranut
dermatita atopica
otita medie
Investigatii
Probe functionale
procesul inflamator este prezent si in afara exacerbarilor (perioadele asimpt)
sa faca parte din examinarea de rutina, precoce
inainte/dupa brdil/brconstrict
evaluarea reversibilitatii
in general evaluare anuala/exacerbari
PEF-metria
- zilnic, dimineata si seara
- limitat (effort dependent)
Spirometria
- la 20-30 min dupa beta agonist - imbunatatirea cu 12% FEV1
Testarea HRB
- histamina/metacolina cu cresterea % pana la scaderea cu 20% FEV1
- majoritatea copiilor astmatici au HRB chiar in absenta simptomelor (FEV1 scade si mai
mult la testare)
- se face si la effort (EIA)
Alergia
Ig E totale
testarea cutanata = hipersensib imediata la alergeni specifici
De ce testare cutanata?
majoritatea copiilor astmatici au alergie
multi au si DA/rinita
identificarea laergen specific -exclude alergia nesemnif
evitarea expunerii la alergen
expune problema familiei!
Rg pulmonara - nefolositoare, exclude alte afectiuni: eozinofilia (nazala!)
Alte examinari:
T sudorii
imagistica sinusuri
bronhoscopie
ECG
presiune gaze sanguine

Cauze frecvente de exacerbari astmatice la copil:

infectii virale
expunere la alergeni
efort sustinut
aer rece
poluare
expunere la fum de tigara
stress

Decesul in astm (astmul mortal)

rar - 5500/an
nu a scazut in ciuda cunoasterii si largirii arsenalului terapeutic
decese nu intotdeauna la severi (1/3)
MONITORIZARE!
Risc crescut de deces in astm - Istoric de astm fatal
Spitalizare, vizita de urgenta in anul precedent
Folosire curenta CST orali/oprit recent
Supradependent de SABA
Istoric de probleme psihosociale, negarea bolii/severitatii
Istoric de noncomplianta la tratament
Tratamentul astmului = restaurarea respiratiei la un nivel de functionare fizica si emotionala
va tine seama de aspectele variate ale vietii copilului
ce este normal?
Scop:
simptome minime(ideal fara) in timpul zilei si noptii
episoade astmatice minime (fara)
folosirea minima, <1/zi beta 2 agonisti
PEF >80% prezis
efecte adverse minime de la medicatie
activitate normala, absenteism scolar redus

Niveluri de control ale astmului

Controlul mediului: polen, pets (animale de companie), mucegai, acarieni, Fumat

Factori ce afecteaza aderenta la tratament
frecventa, timpul administarrii
oral.inhalator.injectabil
confuzie, incertitudine
efecte secundare
costuri, disponibilitate
debutul actiunii
educatia despre astm
Eficienta = eficacitate x aderenta
Reliever
- simptome acute
- prevenirea astm de efort
Ex: beta 2 agonisti CST oral ipratropium bromid
Controller
- zilnic/cronic
- controlul astmului
- prevenirea exacerbarilor
Ex: CST inh , antag recept LT, LABA , teofiline retard, CST orali*

Medicatia antiastmatica la copil = greu de stabilit profilul eficienta/efecte adv <12 ani
Controller
1. CST inhalatori = gold standard
- cele mai eficiente AI
- sigure in doze corespunzatoare
- tipuri diferite de produse
- multe sunt eficiente x1/zi
- se stie f multe despre ef AI in astm
- inhalare corecta
- steroid fobia (educatie!)
- efecte adverse la doze mari, sensibilitate
- afecteaza cresterea?
Doze 200-600 microgr/zi
doze>800 microgr efecte sistemice
!!! atentie la efecte asociate cu CST orali
!!nu se asociaza cu macrolide perioade>
!adaugarea altui controller -scade dozele ICT step down

2. Antagonistii receptorilor de LT/inhibitori sinteza (Montelukast, Zafirlukast); 4,5,10 mg

- oral = avantaj
- MTK 6l-5 ani
- debutul actiunii la cateva ore - mai mult
- reduc param inflamatori fara ef adv ale CSt
- sigure
- indicate in EIA
- ajung pe cale sang in CA mici
+loratadina/alt AH eficiente in rinita
+ICS scad dozele de ICS

3. Teofiline/alte metilxantine
- efecte AI modeste
- nivel terapeutic de 12-24 ore moitorizare sang (15 microgr/dl)
- ef adverse: hiperreactiv, greturi, cefalee, insomnie, atentie<

4. LABA (Formoterol, Salmeterol) NU SINGURE! - efecte AI scazute, tahifilaxie

LABA+ICS
- salmeterol + fluticazona (Seretide 25/50; 50/100; 50/250; 50/500)
- formoterol + budesonide
- cresc sensib recept pt CST
- se pot scade la x1/zi (doze fixe de LABA)

Reliever
salbutamol
anticolinergice
Optiuni terapeutice
Brittle asthma
- atacuri precipitate
- indivizi f alergici
- uneori la expunere la animale, alimente
- sever +/- anafilaxie
- tratament beta2 prompt, adrenalina sc

Sugari
- parinti anxiosi
- infectii virale, Ab rar!
- durata 2-3 saptamani
- nici o medicatie eficienta
- trial beta2 inh
- tusea eficienta!
- hidratare
- P 1-2mg/kg/zi daca nu cedeaza/se agraveaza
-spitalizare:neliniste, inapetemta, cianoza, desh, epuizare, socioec

Prescolari
infectii resp frecv - alergen>

Scolar = astm pediatric - control max!

Adolescenti
nevoi speciale
independenta
fumat NU!
! sg medicatie controller

Tratamentul exacerbarilor acasa

Tratamentul exacerbarilor la spital/urgenta

Exacerbarea astmatica pe scurt

Oxigen (saturatie <95%)
SABA inhalator (2-4 puf la 20 min in I ora, la 1-2 ore)
CST orali 0,5 -1 mg/kg/injectabil

NU SE FOLOSESC:
SEDATIVE
MUCOLITICE
FIZIOTERAPIE
HIDRATARE CU VOLUME >
ANTIBIOTICE
EPINEFRINA
SULFAT DE MG

Criterii de severitate in AB la copil

GINA 2006 CE SE STIE DESPRE ASTM

Una dintre cele mai frecvente boli 9fficie in lume
Prevalenta 1-30% (in crestere la copilul mic)
Poate fi tratat 9fficient
Majoritatea pacientilor obtin controlul bolii
Astm controlat la copil
-se evita simptome diurne/nocturne
-folosirea rara/ deloc a medicatiei reliever
- viata activa, productive
-FP ~ normala
- se evita atacurile severe

Caracteristici AB
A = episoade de wheezing, lipsa de aer, tuse (noaptea, dimineata)
A = boala cr inflamatorie a CA
FR comuni:
exp la alergeni (praf casa, par animale, polen mucegai)
iritanti ocupationali
fum tigara
infectii respiratorii (virale)
efort
emotii puternice
iritanti chimici
medicamente (aspirina, Beta blocanti)
Abordarea farmacologica in trepte pt OBTINEREA si MENTINEREA CONTROLULUI
avand in vedere:
siguranta tratamentului
potentiale efecte adverse
costurile
Exacerbarile A = episodice, INFLAMATIA CA PREZENTA
Multi pac cu trat controller previn exacerbarile, simptomele, FP~N; iar reliever ocazional
Pt obtinerea si mentinerea controlului = PARTENERIAT pacient-familie-medic
! AB nu e un motiv de rusine!

DIAGNOSTICUL SI TRATAMENTUL ASTMULUI IN COPILARIE: RAPORTUL CONSENSUS

PRACTALL

Consensul PRACTALL
= Ghid de practic clinic ce se adreseaz astmului pediatric
- European Academy of Allergy and Clinical Immunology
- American Academy of Allergy, Asthma and Immunology
Premize
Astmul este cea mai frecvent boal cronic la copil n rile industrializate (studii: 50-80%<5ani)
Dovezi clinice limitate despre aspectul specific al astmului pediatric
Variabilitatea istoricului natural al bolii
Triggeri variabili
Fenotipuri / fiziopatologie specifice vrstei
Nici un ghid internaional recent dedicat exclusiv astmului pediatric
Raportul consensual PRACTALL EAACI / AAAAI este primul ghid pentru diagnosticul i
tratamentul astmului creat de specialiti n pediatrie pentru practicienii care trateaz copii

The rationale for a Consensus Report on childhood asthma was founded on facts such as the
following:
- Asthma continues to be the most common chronic disease in children in nearly all industrialized
countries.1
-The evidence base for specific aspects of pediatric asthma is limited.
-No recent international guidelines have focused exclusively on pediatric asthma.
Defining the disease itself can be a challenge, given the variable natural history of asthma in children
in general and infants and preschool children in particular.
Asthma triggers, particularly allergens, can also be variable with respect to seasonality, geographic
regions, and indoor versus outdoor exposure. As a child grows, his or her triggers may also shift
among various inhaled allergens.
Childhood asthma reflects a heterogeneity of age-related phenotypes, with distinct features among
infants 0 to 2 years of age, preschool children 3 to 5 years of age, school children 6 to 12 years of age,
and adolescents. The responsiveness of children with asthma to pharmacotherapy must be monitored
carefully with adjustments made, as appropriate.
The choice among pharmacotherapeutic options needs to be carefully considered because individual
children of various ages respond differently to pharmacotherapy.

Istoric natural
Pn la vrsta de 3 ani pn la 50% dintre copii vor avea cel puin un episod de wheezing
60% dintre copii cu wheezing infantil vor fi sntoi la vrst colar
Copiii precolari i colari cu exacerbri virale recurente = astm indus viral
Fenotipurile n funcie de trigger

1000 Asthma score

Grass pollen
800

600
Efectul vrstei
400 Fenotipuri n funcie de:
Vrst:
Copii mici (0-2 ani)
200 precolari (3-5 ani)
Copii
Copii colari (6-12 ani)
Adolesceni
0
Triggeri:
Astm 1981
indus viral 1982 1983 1984
Astm indus de execiii (activitate)
Astm indus de alergeni

Copiii mici: Wheezing

Copiii prescolari:
Virusurile - cel mai frecvent trigger la aceasta varsta
Astmul indus viral - cel mai frecvent fenotip
Astmul indus de activitate - destul de frecvent

Copiii scolari:
Astmul alergic - mai frecvent fata de prescolari
Astmul indus viral - in continuare frecvent si la acest grup

Adolescenti:
Multi sunt refractari la utilizarea regulata a tratamentului
Nu accepta restrictii
Fumatul = problema
Identificarea fenotipului astmului este esenial

Various asthma phenotypes can be defined on the basis of the childs 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
Diagnostic
Anamneza
Examenul clinic
Alergii mediate IgE
Alte teste
- radiografie pulmonar, eNO, aerul condensat expirat etc.
-Evaluarea funciei pulmonare
-Testul de reactivitate bronic

Diagnostic diferenial i comorbiditi

The diagnosis of asthma continues to pose challenges in pediatric patients, particularly in infants and
preschool children. Recurrent wheezing and episodes of coughing should raise suspicion for the
diagnosis in any infant. The clinician will also need to consider and ask about the potential role of
triggers, such as passive smoke, pets, altered sleep patterns that may involve awakening, night cough,
or sleep apnea, or exacerbations within the past year. The presence of nasal symptoms, such as
running, itching, sneezing in all children, with particular attention to nasal structures and listening for
forced expiration, should also be evaluated.1
Evaluation of IgE-mediated allergy should involve in vivo and in vitro testing for allergies, as well as
other tests, such as chest x-ray, exhaled nitric oxide, or exhaled breath condensates, that may indicate
the presence of allergic inflammation.1
Assessment of lung function in terms of peak expiratory flow or forced expiratory flow is
recommended, with evaluation of bronchodilator responsiveness as a measure of the reversibility of
airflow limitations with a 2-agonist.1
Finally, differential diagnosis of asthma must exclude other potential etiologies for asthma symptoms
in children, particularly in the presence of comorbidities that might aggravate the situation.1

Cnd trebuie s suspicionm un astm bronic?

Ce urmrim la un copil? Ce ntrebm?

La toi copiii:
wheezing, tuse
trigeri specifici: ex. fumatul pasiv, animale de cas, umiditate, mucegai i igrasie, infecii respiratorii,
expunere la aer rece, exerciiu/activitate, tuse dup rs/plns
somn alterat: treziri, tuse nocturn, apnee de somn
exacerbri de-a lungul ultimului an
simptome nazale: rinoree, mncrimi, strnut, nas nfundat

La copiii mici(<2 ani):

Respiraie zgomotoas, vomitat asociat cu tusea
Retracie costal
Dificultate n alimentare (sunete, supt anevoios)
Modificarea ratei respiratorii

La copii peste 2 ani:

Scurtarea respiraiei (ziua sau noaptea)
Oboseal (se joac mai puin dect copii de aceeai vrst, iritabilitate crescut)
Se plng c nu se simt bine
Performan colar sczut sau absene colare
Reducerea frecvenei sau a intensitii activitii fizice,
ex. la orele de sport
Evitarea altor activiti (somn prelungit, evit vizitarea prietenilor cu animale de cas)
Triggeri specifici: sport, orele de gimnastic, activitate

Adolescenii
Fumatul?
PRACTALL: Managementul astmului

The Pediatric Consensus Report reinforced that management of asthma in children should be founded
on a comprehensive treatment plan individualized to each specific patients 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

Msuri de evitare
Se recomand testarea sensibilizarii la alergeni precum i stabilirea clar a unei asocieri ntre
expunerea la alergeni i simptomatologie
Testarea la alergeni (indiferent de varsta)
Evitarea expunerii la fumul de tigara
Dieta echilibrata si evitarea aparitiei obezitatii
Activitatea fizica NU trebuie evitata

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

Farmacoterapia: controlul astmului la copil

Astmul este bine controlat atunci cnd urmtoarele elemente sunt atinse i meninute:
-Simptome diurne mai puin de 2 pe sptmn (nu mai mult de odat pe zi) Fr limitarea activitii
datorat astmului
-Simptome nocturne mai puin de odat pe lun
-Medicaie de criz utilizat mai puin de dou ori pe lun
-Funcie pulmonar normal (dac se poate msura)
-0-1 exacerbri n ultimul an
Recomandri de terapie medicamentoas la copii ntre 0 i 2 ani

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 childs 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
Tratamentul medicamentos (copii > 2 ani)

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 patients 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

PRACTALL recomand folosirea fie a CSI sau a LTRA ca i terapie iniial de control pentru astmul
persistent
Tratament de prim intenie pentru astmul persistent
Dac astmul este insuficient controlat ar trebui introdus iniial ca tratament de meninere
Atopia i afectarea funciilor pulmonare anticipeaz un rspuns favorabil
Dac dozele mici nu asigur un control adecvat trebuie identificat motivul. Dac este necesar se ia n
considerare creterea dozei de CSI sau adugarea LTRA sau BADLA
Efectul la copii mai mari dispare la ntreruperea tratamentului
Exista dovezi ca la prescolari CSI nu modifica cursul bolii dup ntreruperea tratamentului
PRACTALL recomand folosirea fie a CSI sau a LTRA ca i terapie iniial de control pentru astmul
persistent
Tratament alternativ de prim intenie pentru astmul persistent
Doveziile clinice sprijin folosirea LTRA ca i terapie iniial de control pentru astmul uor la copii
Vrsta mai mic (sub 10 ani) precum i detectarea unor nivele crescute de leucotriene urinare
anticipeaz un rspuns favorabil
Terapie pentru pacienii care nu pot sau nu doresc s utilizeze CSI
Util i ca terapie add-on la CSI: mecanism de aciune diferit i complementar
Sugerat n tratarea wheezing-ului indus viral la copiii mici
Beneficii dovedite la copii ncepnd de la vrsta de 6 luni
LTRA pot fi n special utile la pacienii care au i rinit
Terapie add-on la CSI pentru astmul parial controlat / necontrolat
Nu este bine documentat eficacitatea la copii
Datorit problemelor profilului de siguran, folosirea acestora trebuie limitat la terapie add-on la CSI
cnd este cazul
Combinaia CSI / BADLA este permis la copii peste 4 sau 5 ani; (efectele BADLA sau ale
combinaiilor nu a fost studiat adecvat la copii sub 4 ani).

Some studies suggest that there is an increase in asthma exacerbations and risk of hospitalization in
patients using LABAs regularly.1
The Pediatric Consensus Report comments that LABAs may be used as add-on therapy in pediatric
patients with partially controlled or uncontrolled asthma treated with ICS. The report further states that
LABAs should always be used together with an ICS and that, until more evidence becomes available
to support the effectiveness and long-term safety of LABAs, these agents should not be used in a
regimen without an appropriate dose of an ICS in these patients.1
Notably, the efficacy of LABAs is not as well documented in children as it is among adults with
asthma. Accordingly, LABA therapy should be closely monitored in children.1
The report further cautions clinicians to remember that, although combination products containing a
LABA and an ICS may be licensed for use in children over 4 to 5 years of age, the effect of LABAs or
combination products has not yet been adequately studied in young children under 4 years of age.1

Other pharmacotherapy recommendations include oral theophylline, cromolyn sodium

(nedocromil) and anti-IgE antibodies

Recomandri pentru imunoterapie

Necesit alergenii adecvai pentru astmul alergic
Utilizat alturi de controlul adecvat al mediului i terapia medicamentoas
Nu este recomandat cnd astmul este instabila
a
n ziua tratamentului, pacienii trebuie s prezinte simptome minime sau deloc, iar funcia pulmonar
(FEV1) s fie cel puin 80% din valoarea prezis.

The Pediatric Consensus Report addressed immunotherapy with the following recommendations.1
Immunotherapy should be planned with the use of allergens appropriate for individual patients who
have allergic asthma and these allergens should be used within their licensed indications. The
allergenic component of the patients asthma should be well documented and reliable allergen extracts
must be used since the efficacy of therapy will be dependent on the quality of the extracts.1
Immunotherapy should be used within a comprehensive treatment approach that also includes
environmental control for allergen avoidance, pharmacotherapy, and patient education.1
Immunotherapy should not be administered when a patients asthma is unstable. This means that, on
the day of treatment, the patient should have few, if any, symptoms of asthma and his or her
pulmonary function should be at least 80% of the predicted value of FEV1.1
While sensitization to more than 1 allergen is not a contraindication for immunotherapy in patients
with allergic asthma, it can reduce the efficacy of therapy. This is due to the need to limit the dose of
individual allergens when several are administered concurrently.1
Young age may not necessarily be considered an absolute contraindication to immunotherapy. The
consensus report suggests that such therapy may be used from the age of 3 years even though this is
well below the current licensed age limit. Immunotherapy must be administered with caution and only
by well-trained personnel in the presence of a physician experienced in its use. All appropriate
cautions must be taken and provisions for emergency treatment, including life support, must be
available.1
Finally, physicians prescribing immunotherapy must ensure that their pediatric patients are complying
with other treatments, including avoidance measures and pharmacotherapy.1

Recomandri pentru imunoterapie

Sensibilizarea la mai mult de un alergen nu reprezint contraindicaieb
Vrsta nu reprezint o contraindicaiec absolut
Pacienii trebuie s fie compliani i cu celelalte tratamente

Recomandri privind educaia

Persoane afectate
- copii
- parinti
- ingrijitori

Personal specializat medical

- medici de familie
- asistente
- farmaciti
- lucrtori n educaia pentru sntate i grupuri de suport pentru pacieni
- Autoriti sanitare i politicieni

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 childs
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 childs treatment plan at each
consultation. A 3-tiered educational program would then be implemented in a manner appropriate for
the childs 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 childs 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

Recomandri: concluzii
Tratamentul inflamaiei cilor respiratorii conduce la controlul optim al astmului
CSI i LTRA sunt recomandate ca terapii de control iniiale pentru astmul persistent
Pn la apariia unor noi dovezi de eficacitate i siguran pe termen lung, BADLA nu trebuiesc
utilizate fr doza potrivit de CSI
Imunoterapia se adaug farmacoterapiei i controlului mediului
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