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PG 1 Asthma and COPD:
Asthma exacerbations in children: the paediatrician’s view
Saturday sept 3rd 2016
12.00-12.30 hrs
Bart Rottier, MD PhD
Department of Pediatric Pulmonology and Allergology
University Medical Center Groningen/Beatrix Children’s Hospital
disclosure I have no real or perceived conflicts of interest that relate to this presentation.
Educational aims
At the end of this interactive (so please interrupt and
interact) workshop participants
• Will have gained some experience in looking at pediatric patients
with exacerbations
– Commmon ground and differences with exacerbations in adults
• Will feel updated on pediatric asthma treatment
• Be aware of new scoring and communication systems
Beatrix Children’s Hospital
Eosinophilic Asthma
Neutrophilic
Mixed COPD
The 7 dwarfs with ACOS
Smoky Sneezy Wheezy Phlegmy Puffy Grumpy Chesty
What can go wrong with a biological tube?
Obstructive diseases
• Cystic Fibrosis
• Asthma
• Survivors of prematurity
• Obliterative bronchiolitis
• Primary Ciliary dyskinesia
• (non CF) bronchiectasis
Early life origins
Sudden severe narrowing of the biological tube:
“exacerbation” or “flare-up”
A flare-up or exacerbation is an acute or sub-acute worsening
of symptoms and lung function compared with the patient’s usual status
Terminology
‘Flare-up’ is the preferred term for discussion with patients
‘Exacerbation’ is a difficult term for patients
‘Attack’ has highly variable meanings for patients and clinicians
‘Episode’ does not convey clinical urgency
GINA 2016 © Global Initiative for Asthma
Case https://youtu.be/PeehWsHKH4w
Kate, 2 years
History
Common cold
Since 2 days:
Shortness of
breath
-coughing
- temp.: 38°C
Mildly ill, coughing
Tachypnoeic
Mild retractions
Your observation: Nasal flaring
Difficulty in exhalation as seen by active
abdominal musclesKate, 2 years History Common cold Asthmatic flare-up? Since 2 days: - Shortness of breath - coughing - temp.: 38°C Your observation Mildly ill, coughing Tachypnoeic Mild retractions Nasal flaring Difficulty in exhalation as seen by active abdominal muscles
Kate, 2 years History Common cold Since 2 days: - Shortness of breath - coughing - temp.: 38°C Your observation Mildly ill, coughing Tachypnoeic Mild retractions Nasal flaring Difficulty in exhalation Auscultation: Left side in- and expiratory crackles Wheezing? Right side prolonged expiration/wheezing
Asthmatic flare-up:
The september-epidemic
J Allergy Clin Immunol 2006;117:557-62.Asthma flare-ups
• common cold viruses were found in 80-85% of reported
exacerbations of asthma in children
– Rhinoviruses accounted for two thirds of viruses detected
– In 2016, enterovirus D68 (EV-D68) was causing severe exacerbations leading
to PICU admission in Groningen
• Peaks in cases occur at the beginning of autumn in children
and in winter in adults Johnston S, BMJ 1995;310:1225
Nicholson K, BMJ 1993;307:982-6
Altzibar J, Clin Exp Allergy. 2015Aims of asthma treatment: • Asthma control! (BTS, GINA, NAEPP) – no daytime symptoms – no night-time awakening due to asthma – no need for rescue medication – no asthma attacks (GINA 2015: “flare-ups) – no limitations on activity including exercise – normal lung function
How to avoid attacks/flare-ups? • Avoidance of triggers where possible • Preventive treatment
In the next months 2 recurrent flare-ups
Assessment of risk factors for poor asthma outcomes
Risk factors for exacerbations include:
• Ever intubated for asthma
• Uncontrolled asthma symptoms
• Having ≥1 exacerbation in last 12 months
• Low FEV1 (measure lung function at start of treatment, at 3-6 months to assess personal
best, and periodically thereafter)
• Incorrect inhaler technique and/or poor adherence
• Smoking
• Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
• No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood
eosinophilia
© Global Initiative for AsthmaIf asthma not controlled on ICS: how to proceed?
• Review diagnosis and consider comorbidity
– Even more important in younger children!
• Consider adherence
• Review inhalation technique
– Consider changing drug or device
• Decide on step 3 therapy
• Follow the difficult asthma protocolHistory: red flags
• Symptoms from birth onward
– Anatomical disorder, primairy ciliairy dyskinesia (PCD), tracheo-oesophageal (TE)
fistula
• Acute onset
– Foreign body aspiration
• Chronical productive cough
– hypogammaglobulinemia, Cystic Fibrosis, PCD, bronchiectasis
• More symptoms with/after feeding, more supine
– TE-fistula, reflux with aspiration
• No symptom free intervalsHistory: red flags (2)
• Abnormal perinatal history
– CLD, surfactant deficiencies
• Stridor
– Upper airway obstruction: vascular rings and slings, hemangioma, laryngeal
abnormalities or malacia
• Failure to thrive
– CF, PCD, recurrent infections, cardiac abnormalities
• Feeding difficulties
– Cardiac and neurologic disordersPhysical Examination: red flags
• Failure to thrive (insufficiant weight/height gain)
– CF, immunological disorder
• Mouth breathing, rhinitis
– large adenoïd, post nasal drip
• Inspiratory stridor:
– Abnormality of larynx or extra thoracal trachea
• Unusually severe chest deformity ( PA diameter)
– CF, severe asthma
• Localized findings on auscultation, monophonic wheeze, crackles,
– Foreign body aspiration, anatomical disorders, endobronchial disorders, bronchiectasis
• Murmur and/or abnormal heart sounds:
– Cardial (ASD)
• Clubbing
– Hypoxia (cardial), CF, auto-immunological disordersWhen “problematic severe asthma” diagnosed in pediatrics,
how often would it appear not so problematic at all after a
home visit?
1. 20%
2. 50%
3. 70%55% of cases
-Avoid escalation Rx
-Avoid difficult asthma work-up
N = 71When “problematic severe asthma” diagnosed in pediatrics,
how often would it appear not so problematic at all after a
home visit?
1. 20%
2. 50%
3. 70%Problematic severe asthma
EXACERBATION phenotype
Chronic symptoms
phenotype
Hedlin; Eur Respir Rev 2012; 21: 125, 175–185% SYMPTOM FREE DAYS
▪ FP
▫ FP/salm
N= 257 diskus 2 x 100 µg run in 1 month
LACK OF SYMPTOMS N = 72!
Still symptoms after run in:
-N=80 FP 2x daily 200 µg
-N=78 FP/Salmeterol 2 x daily 100/50 µgBenefit of higher ICS vs LABA
Time to first course of prednisone
Combination: FLuticasone 2 dd 100µg
1 dd 100 FP/50 salmeterol
1 dd 50 salmeterol
Montelukast 1dd 5-10 mg
Sorkness et al, J Allergy Clin Immunol 2007;119: 64-72Lemanske et al
FP 2 dd 250
FP/SALM 2dd 100/50
Composite endpoint: FP 2 dd 100+montelukast 5-10
- Prednisolone
- asthma control days
-480
FEV1> 298 excluded > N = 182 uncontrolled asthma while receiving FP 2 dd 100; triple cross overCould not be predicted by FeNO or bronchodilator response…………
Asthma flare-ups • Should be prevented • ICS should do the job • Consider triggers, adherence, inhalation technique • Stepping up: double ICS or adding LABA • Now: life threatening exacerbations
Evidence based medicine in life
threatening asthma?
useful vs harmful
evidenceSummary of the educational aims
• How to recognize an astma exacerbation
– Effort Efficacy and effect on other organs
– Pediatric early Warning Scores (PEWS) and SBARS (situation-background-
• Exacerbations are virally induced (“September epidemic”)
– ICS as step one preventer therapy
– High dose SABA’s, Oxygen, Magnesium, Salbutamol/terbutalin IV
• Similarities and differences between asthma exacerbations in children and
adults
– Not too different after all?You can also read
