ASTMUL BRONSIC SI

WHEEZINGUL RECURENT LA
COPIL
 DEFINITIE

� Boala inflamatorie cronica a CA

⮚ hiperreactivitate bronsica
⮚ inflamatie bronsica
⮚ obstructie bronsica reversibila
 EPIDEMIOLOGIE
� Cea mai frecventa boala cronica a copilului
� Prevalenta
⚫ 9.3% SUA
⚫ 5-27% Europa
⚫ 4-6% Romania

� PREVALENTA SI SEVERITATEA IN CRESTERE!

� Cauza de mortalitate si morbiditate (spitalizari
repetate 🡪 costuri importante)
ETIOLOGIE
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 FIZIOPATOLOGIE
� inflamatie bronsica
• bronhii medii🡪 tot ap.respirator

� hiperreactivitate bronsica
• ingustare excesiva a bronhiilor la diversi stimuli

� obstructie bronsica reversibila

• 🡪 limitare flux aer
• 🡨 bronhoconstrictie + inflamatie mucoasa bronsica
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 FIZIOPATOLOGIE
� celule infl.
◦ mastocite, eozinofile, LTh2, bazofile
◦ rol: raspuns la tratament, remodelare bronsica

� celule struct.
◦ cel. epit, cel. musculare netede, cel. endoteliale, fibroblasti
◦ rol: inflamatie, bronhoconstrictie, remodelare bronsica

� mediatori infl.
◦ His (bronhoconstrictie)
◦ LT (inflamatie bronsica, bronhoconstrictie)
◦ PAF, kinine (bronhoconstrictie, inflamatie, secretie mucus)
◦ oxid nitric, CK, chemokine (inflamatie bronsica)
◦ factori crestere celulara (remodelare bronsica)
 TABLOU CLINIC

• dispnee expiratorie EXAMENUL FIZIC

• wheezing •NORMAL in afara exacerbarilor
• tuse spastica persistenta •polipnee/bradipnee

• constrictie toracica •hiperinflatie toracica

• caracter episodic •expir prelungit, raluri sibilante
• recurenta •tahicardie

•falsa hepatomegalie
 MANIFESTARI CLINICE

�1. Criza de astm

�2. Starea de rau astmatic
�3. Starea intercritica

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 CRIZA DE ASTM
� = paroxism de dispnee respiratorie reversibila
spontan/BhD
� clinic: dispnee E + polipnee (sugar)/ bradipnee (copil
mare); tiraj IC, batai aripi nazale, E prelungit,
wheezing, tuse uscata 🡪umeda ± cianoza
� ex obiectiv: copil anxios, ortopnee, torace destins,
falsa H-meg, diminuarea AMC, raluri Si/Su, evolutie
ore
� sfarsitul crizei: ameliorare simpt si SFR, tuse
frecventa, expectoratie perlata
 STAREA DE RAU ASTMATIC
� = paroxism dispnee E, sever, durata>24 h, fara raspuns la
BhD
� faza de lupta: dispnee E intensa, cianoza, inspir scurt, tiraj,
batai aripi nazale, tahipnee, torace hiperinflat, hipersonor,
diminuare MV
� faza de bronhoplegie: bhspasm🡪 bhdilat, tahicardie, tulb
ritm, IC, HTA🡪hTA, colaps, anxietate, somnolenta,
hiporeactivitate, convulsii🡪 coma🡪 SCR.
� gravitate: dispnee marcata, cianoza, bradicardie, balans
toraco-abdominal, “silentiu” auscultator, epuizare, alterare
constienta, Sa02<91%, PaO2<60 mm Hg, PaCO2> 45 mm
Hg 14
 INTERCRITIC
� pacient asimptomatic
� tablou clinic cvasinormal
� simpt. cronica (severitate/controlul terapeutic)
⚫ tuse cronica
⚫ dispnee expiratorie
� astm bronsic sever:
⚫ IRC
⚫ deformari toracice
⚫ cianoza, hipocratism digital
⚫ hipotrofie staturo-ponderala
⚫ pubertate intarziata 15
 DIAGNOSTIC POZITIV
� suspiciune clinica 🡪 anamneza 🡪 analize
specifice🡪 raspuns terapeutic
� criterii:
◦ tuse, wheezing, constrictie toracica si dispnee
◦ variabilitatea + recurenta simpt.
◦ demonstrarea variabilitatii limitarii luxului de
aer: FEV1, VEMS, FVC, PEF (> 6 ani)

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 WHEEZING RECURENT
� 50% copii 1 episod wheezing < 6 ani
� WR = ≥3 epis wheezing in 12 luni
� rhinovir si VSR 🡪 epis WR
� WR episodic: trigger viral, simpt viroza, fara wheezing intre
episoade
� WR cu triggeri multipli : IACRS pe fond atopic, wheezing
intre episoade
� WR tranzitoriu: tablou clinic<3 ani, dispare<6 ani, fara
atopie
� WR persistent: simpt<3 ani, continua>6 ani, +atopie
� WR tardiv: simpt > 6 ani, + atopie
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 DIAGNOSTIC < 5 ANI
� nu se pot efectua teste respiratorii
� pattern-ul epis. wheezing
� manifestarile clinice
� prezenta atopiei
� istoric familial AB/atopie
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 DIAGNOSTIC AB
� wheezing >10 zile, sever, pp de ef. fizic, poluanti, fum
tigara, plans, ras, acc. nocturn
� tuse seaca recurenta/persistenta, agravata nocturn/ef. fizic,
pp de poluanti, fum tigara, ras/plans
� dispnee declansata de ef. fizic/ras/plans
� activ fizica redusa
� istoric familial AB ± atopie
� istoric personal atopie ± boli alergice
� proba terapeutica (CSI low dose 2-3 luni 🡪 ameliorare)

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 API (INDICE PREDICTIE ASTM)

� > 6 ani
� pozitiv: < 3 ani cel putin 3 epis wheezing/an, 1 criteriu
major sau 2 minore
� criterii majore:
⚫ dermatita alergica
⚫ parinte AB
� criterii minore:
⚫ rinita alergica
⚫ eozinofilie>4%
⚫
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wheezing in afara episoadelor acute virale
 NU AB
� simpt legate de infectii
� tuse izolata fara wheezing/dispnee
� tuse productiva
� examen fizic repetat N
� PEF sau spirometrie N la copil simptomatic
� fara raspuns la terapia specifica
� manif clinice sugestive 🡪 diagnostic diferential

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 DIAGNOSTIC DIFERENTIAL
� BRGE, FC, TBC
� aspirare corp strain
� traheomalacie
� diskinezie ciliara
� displazie bh-pulm
� deficite imune
� malf cardio-vasc, digestive, bh-pulm
� bronsiolita acuta
� bronsiolita obliteranta
� bronsiectazii “perete subtire”
� epilepsie diencefalica
� wheezing viral
� def α1-antitripsina
� pneumonie hipersensib
� aspergiloza pulm alergica
� compres mediast (arc vasc, limfom, tumori) 22
 INVESTIGATII
� Spirometrie: FEV1, VEMS, FVC, PEF
� pletismografie
� HLG – eozinofile
� ex. sputa – eozinofile
� Rx 🡪 dgn dif, complicatii
� FeNO – marker non-invaziv inflam alergica, controlul bolii
(N: 5-20 ppb < 12 ani, 5-25 ppb> 12 ani)
� PaO2, PaCO2, pH – exacerbari AB
� CT torace/sinusuri, testul sudorii, ph-metrie, rino-
laringoscopoie, bh-scopie – dgn dif
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 EXPLORARE ALERGOLOGICA
� identificare alergeni
� documentare atopie

� teste :
⚫ testare cutanata (prick-test)
⚫ dozarea IgE globale
⚫ dozare IgE specifice in ser (RAST) –
relevanta, costisitoare

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 FENOTIPURI AB
� astm usor cu atopie redusa , rata redusa exacerbari
� astm atopic cu obstr bronsica, rata medie
exacerbari
� AB cu obstr bronsica severa, rata medie
exacerbari
� AB cu atopie moderata, obstr bronsica severa,
rata crescuta exacerbari
� AB cu atopie crescuta, obstr bronsica severa, rata
crescuta exacerbari 27
 CLASIFICAREA SEVERITATII AB
simptome exacerbari Simptome FEV1 Variabilitate
nocturne sau PEF FEV1 sau PEF

INTERMITENT <1 /sapt scurte < 2/luna ≥80% <20%

USOR >1/sapt, <1/zi Afecteaza >2/luna ≥80% <20-30%

PERSISTENT activitatea/s
omnul

MODERAT zilnice Afecteaza >1/sapt 60-80% >30% SABA

PERSISTENT activitatea/s zilnic
omnul

SEVER zilnice frecvente frecvente ≤60% >30% Limiteaza

PERSISTENT activitatea
fizica
 MANAGEMENT AB
� masuri farmacologice:
⚫ trat. exacerbari (reliever)
⚫ trat. cronic (controller)
� masuri non-farmacologice
⚫ corectare dieta + obezitate
⚫ excludere alergeni mediu
⚫ vaccinare antigripiala + antipneumococica
⚫ consiliere psihologica
⚫ trat.comorbiditati 29
 simpt. limit. simpt. reliever fct. pulm exacerbari
diurne activ. noct. (FEV1,
PEF)

AB controlat ≤ 2/ sapt nu nu ≤ 2/ sapt N nu

AB partial ≥ 2/ sapt oricare oricare ≥ 2/ sapt < 80% din 1/an

controlat val.
prezisa

AB ≥ 3 caracteristicile AB partial controlat 1/sapt

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necontrolat
 MEDICATIE CONTROLLER
� reduce inflamatia
� control manif. clinice
� reduce riscul exacerbari
� stop declin fct. pulmonara
� CSI: fluticazona, beclometazona, budesonid
� CSI 🡪control. infl. bronsica 🡪 reduce simpt.,
hiperreactiv br, frecv, severitatea exacerbari 🡪 limit.
mortalitatea astm 🡪 ameliorare calit. vietii si fct. pulm

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 MEDICATIE CONTROLLER
� LTRA: montelukast, zefirlukast
⚫ reduc simpt.
⚫ amel. fct. pulm
⚫ reduc infl. bronsica si exacerbari
⚫ eficienta < CSI

� LABA: formoterol, salmeterol

⚫ NU monoterapie, + CSI
⚫ reduc simpt. diurne+ nocturne, exacerbari
⚫ amel. fct. pulm
⚫ scad necesarul reliever si doza CSI pt controlul AB
⚫ NU < 5 ani
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 MEDICATIE CONTROLLER
� teofilina
⚫ bhdilatator durata lunga act.
⚫ pacienti necomplianti la trat. inh
⚫ NU la copil < 11 ani
� cromone inh
⚫ eficienta redusa
⚫ prevenire exacerbari induse de ef. fizic
� CS oral
⚫ forme severe
� MoAb (anti IgE)
⚫ terapie adjuvanta in astm alergic sever
⚫ Omalizumab : urticaria idiopatica cronica, polipoza nazala
⚫ Mepolizumab: SHE, EGPA
⚫ Benralizumab
⚫ Dupilumab: rinuzita cronica cu polipoza nazala, dermatita atopica 33
 MEDICATIE RELIEVER
� oricand la nevoie
� in exacerbari, prevenire bhspasm indus de efort
� SABA : salbutamol, albuterol, terbutalina
� anticolinergice inh: bromura ipratropiu
◦ eficienta < salbutamol
◦ intol.la salbutamol
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PRINCIPII DE TRAT.
� AB persistent 🡪 prima alegere
◦ copil 🡪 CSI
◦ adolescent 🡪 CSI + LABA
� step-up si step-down – raspuns la tratament
� 2-3 luni trat. 🡪 fara control 🡪 step-up
◦ ! tehnica inhalatorie
◦ complianta trat.
◦ expunere triggeri
◦ comorbiditati
◦ dgn?
� control > 3 luni + risc scazut exacerbari 🡪 step-
down 35
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 EXACERBARE
� usoara sau moderata � severa

◦ rosteste fraze ◦ rosteste cuvinte, agitat, inclinat in

fata
◦ ortopnee + polipnee
◦ polipneic (FR>30/min)
◦ nu fol. mm accesorie
◦ utili. mm accesorie
◦ tahicardic (100-120 bpm)
◦ tahicardic (>120 bpm)
◦ SaO2 = 90-95%,
◦ SaO2 < 90%, PEF < 50%
◦ PEF > 50 %
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 FR EXACERBARI
� simpt necontrolate
� consum excesiv SABA (>200 puf/luna)
� utilizare inadecvata CSI
� FEV1 scazut (<60%)
� probl. psihologice/socio-ec. majore
� expunere fum tigara/alergeni
� comorbiditati (obezitate, rinosinuzita, alergii alimentare)
� eozinofile crescute (sputa/sange)
� sarcina
� exacerbare severa in APP 48
FR remodelare bronsica FR reactii adverse la trat.

� lipsa CSI in trat.

� utilzare frecv. CSO
� expunere fum tigara, noxe
� utilizare indelungata CSI
� FEV1 scazut
high dose
� eozinofilie
� tehnica deficitara inhalare
� hipersecr. cronica mucus

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 TRAT. EXACERBARI
� domiciliu :
⚫ 2-4 puff salbutamol ± spacer
⚫ fara ameliorare 🡪 repeta la 20 min
⚫ ameliorare 🡪 repeta doza la 4-6 h, 3-5 zile
� fara raspuns 🡪 creste doza CSI sau CSI +
LABA + CS oral
� fara raspuns sau PEF < 50% 🡪 asistenta
medicala
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 TRAT. EXACERBARI
� spital:
⚫ 4-10 puff Slabutamol spacer/nebulizare la 20 min, pt 1 h, +
bromura ipratropiu, + CS oral sau iv, + O2 (SaO2 < 92-
94%)
⚫ start trat. control
� internare: salbutamol < 4h, O2 >1 h dupa trat.
bhdilat, exacerbari severe in APP, CS oral recent pt
exacerbare, PEF/FEV1<25% inainte de salbutamol
sau < 40% dupa salbutamol, complianta scazuta,
nivel socio-economic scazut
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 TRAT. EXACERBARI
� ATI:
◦ salbutamol inh. + bromura, CS iv + O2
◦ fara raspuns 🡪 MgSO4 iv, ventilatie non-invaziva, B2
agonisti iv + He+O2
◦ IOT + VM

GRAVITATE: obnubilare, confuzie, silentiu

respirator 🡪 internare in sectie ATI
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 EVOLUTIE SI PROGNOSTIC
� factori genetici
� AHC de AB
� atopie
� expunere la alergeni (fum de tigara) 🡪 evolutie
nefavorabila
� pattern variabil (particularitati individuale + factori de
mediu)
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 EVOLUTIE SI PROGNOSTIC

� debut > 6 ani 🡪 manif. clinice adult

� 30-70% copiii cu astm (forme usoare) 🡪
remisia manif. clinice adult
� astm sever 🡪 risc 13x simpt. astm la 50 ani

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