Post on 02-May-2015
Il wheezing prescolareAbbiamo sbagliato
bambino?
Renato CutreraDir. U.O.C. Broncopneumologia
Dipartimento Medicina Pediatrica (Prof. A.G. Ugazio)Ospedale Pediatrico Bambino Gesù IRCCS - Roma
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Salerno PediatriaIl Bambino cresce
Vietri sul mare 29 Novembre 2014
25 %25 %R. Cutrera, 2014, cutrera@opbg.net 2
mm
Allora è asmatica?
mm
Ha di nuovo qualche fischio
Wheezing ricorrente
Il dilemma
R. Cutrera, 2014, cutrera@opbg.net 3
4R. Cutrera, 2014, cutrera@opbg.net
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Asthma and Wheezing in the First Six Years of LifeFernando D. Martinez, et al. (N Engl J Med. 1995;332:133-8.)
No wheezing51%
Transient early
wheezing20%
Late onset wheezing
15%
Persistent wheezing
14%
1246 neonati seguiti fino ai 3 anni e ai 6 anni di vita (826)
Nel 1° anno di vitaIgE cordone (n.750)PFT a < 6 m (n.125)IgE seriche 9m (n.672 A1 anno di vita Questionario (n.800) Primi 3 anni follow-up per patologia basse vie aeree (n.888) A 6 anni di vita questionario sul wheezing (n.1024) A 6 anni di vitaIgE seriche (n.460)PFT (n.526)Skin Tests (n.629)
Tutto iniziò da .. Tucson (almeno per noi pediatri)
R. Cutrera, 2014, cutrera@opbg.net
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Livelli di IgE seriche e prevalenza di positività cutanea ad allergeni inalanti in
relazione al tipo di wheezing.
0
10
20
30
40
50
60
70
Serum IgE(IU/ml)
Positive skintest (%)
No wheezing
Transient earlywheezing
Late onsetwheezing
Persistent wheezing
* p <0.01 ** p <0.001 *** p = 0.003
***
***
Asthma and Wheezing in the First Six Years of LifeFernando D. Martinez, et al. (N Engl J Med. 1995;332:133-8.)
R. Cutrera, 2014, cutrera@opbg.net
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950
1000
1050
1100
1150
1200
1250
1300
6 years
ml/s
No wheezing
Transient earlywheezing
Late onsetwheezing
Persistentwheezing
0
20
40
60
80
100
120
140
< 1 year
ml/
s **
*
Asthma and Wheezing in the First Six Years of LifeFernando D. Martinez, et al. (N Engl J Med. 1995;332:133-8.)
*p <0.01
VmaxFRC durante il 1° anno di vita e a 6 anniin funzione della storia di wheezing.
R. Cutrera, 2014, cutrera@opbg.net
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Differenti fenotipi di wheezing in età pediatrica e relativa prevalenza
Martinez: Pediatrics 2002;109:362
<3 anni
3-6 anni
>6 anni
Pre
vale
nza
d
i wh
eezi
ng
Wheezing precoce
transitorio
Wheezing non-atopico
Wheezing/asmaIgE-associati
Etá (anni)
R. Cutrera, 2014, cutrera@opbg.net
Fenotipi basati sul pattern dei sintomi
Brand P et al. Eur Respir J 2014; 43: 1172–1177
R. Cutrera, 2014, cutrera@opbg.net 10
Eur Respir J 2014; 43: 1172–1177
Post-hoc analysis on data obtained in 166 pre-school children with multiple-trigger wheezing, recruited during an acute wheezing episode.
Compare the efficacy of one week treatment with 400 μg b.i.d. nebulized beclomethasone dipropionate (BDP), plus nebulized 2500 μg prn salbutamol (BDP group), versus nebulized b.i.d. placebo, plus nebulized prn 2500 μg salbutamol (placebo group)
Post-hoc analysis on data obtained in 166 pre-school children with multiple-trigger wheezing, recruited during an acute wheezing episode.
Compare the efficacy of one week treatment with 400 μg b.i.d. nebulized beclomethasone dipropionate (BDP), plus nebulized 2500 μg prn salbutamol (BDP group), versus nebulized b.i.d. placebo, plus nebulized prn 2500 μg salbutamol (placebo group)
Short term efficacy of nebulized beclomethasone in mild-to-moderate wheezingepisodes in pre-school children. Papi A, Nicolini G, Boner AL, Baraldi E, Cutrera R, Fabbri LM, Rossi GA. Ital J Pediatr. 2011 Aug
22;37:39.
Short term efficacy of nebulized beclomethasone in mild-to-moderate wheezingepisodes in pre-school children. Papi A, Nicolini G, Boner AL, Baraldi E, Cutrera R, Fabbri LM, Rossi GA. Ital J Pediatr. 2011 Aug
22;37:39.
Mean coughing score in the first week of treatment; each day represents the cumulative mean coughing score; * p < 0,05 between groups.
Mean coughing score in the first week of treatment; each day represents the cumulative mean coughing score; * p < 0,05 between groups.
Short term efficacy of nebulized beclomethasone in mild-to-moderate wheezingepisodes in pre-school children. Papi A, Nicolini G, Boner AL, Baraldi E, Cutrera R, Fabbri LM, Rossi GA. Ital J Pediatr. 2011 Aug
22;37:39.
Short term efficacy of nebulized beclomethasone in mild-to-moderate wheezingepisodes in pre-school children. Papi A, Nicolini G, Boner AL, Baraldi E, Cutrera R, Fabbri LM, Rossi GA. Ital J Pediatr. 2011 Aug
22;37:39.
Percentage of symptom-free days in the first week of treatment; on day 1 the data is relative to the % of symptom-free patients; * p < 0.05 between groups.
Percentage of symptom-free days in the first week of treatment; on day 1 the data is relative to the % of symptom-free patients; * p < 0.05 between groups.
The percentage of SFDs was significantly higher in the BDP group (54.7%) than in the placebo group (40.5%; p = 0.012), with a 35% relative difference. There were no differences in positive effects of BDP treatment between children with and without risk factors for asthma.
The percentage of SFDs was significantly higher in the BDP group (54.7%) than in the placebo group (40.5%; p = 0.012), with a 35% relative difference. There were no differences in positive effects of BDP treatment between children with and without risk factors for asthma.
CONCLUSIONS:
A 1-week treatment with nebulized BDP and prn salbutamol is effective in increasing SFDs and improving cough in children with wheezing, providing a clinical rationale for the short term use of ICS in episodic wheeze exacerbations in pre-school children.
CONCLUSIONS:
A 1-week treatment with nebulized BDP and prn salbutamol is effective in increasing SFDs and improving cough in children with wheezing, providing a clinical rationale for the short term use of ICS in episodic wheeze exacerbations in pre-school children.
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Long-Term Inhaled Corticosteroids in Preschool Children at High Risk for Asthma – Prevention of Early Asthma in
Kids (PEAK) clinical trialTheresa W. Guilbert et al. N Engl J Med 2006;354:1985-97.
R. Cutrera, 2014, cutrera@opbg.net
R. Cutrera, 2014, cutrera@opbg.net
Model of changes of lung function in healthy subjects
Fletcher & Peto BMJ 1977Vita FetaleInfezioni
Asma/allergiaFumo di tabacco
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R. Cutrera, 2014, cutrera@opbg.net 16
Vita FetaleInfezioniAsma/allergiaFumo di tabacco ?
Model of changes of lung function in healthy subjects
Fletcher & Peto BMJ 1977
R. Cutrera, 2014, cutrera@opbg.net
64 million people COPD worldwide in 2004 (WHO)
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R. Cutrera, 2014, cutrera@opbg.net18
R. Cutrera, 2014, cutrera@opbg.net
00
0.50.5
1.01.0
1.51.5
2.02.0
2.52.5
3.03.0Proportion of 1965 Rate (USA)Proportion of 1965 Rate (USA)
1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998
–59%–59% –64%–64% –35%–35% +163%+163% –7%–7%
CoronaryHeart
Disease
CoronaryHeart
Disease
StrokeStroke Other CVDOther CVD COPDCOPD All OtherCauses
All OtherCauses
More than 3 million people died of COPD in 2005, which is equal to 5% of all deaths globally that
year19
R. Cutrera, 2014, cutrera@opbg.net 20
R. Cutrera, 2014, cutrera@opbg.net
COPD - FATTORI DI RISCHIO
Fattori ambientaliFumo di sigaretta
Fumo passivoFumo materno
Inquinamento outdoor, indoorEsposizione professionale
Crescita del polmoneNutrizione
Infezioni respiratorie
Fattori individualiDeficit alfa1-AT
Stress ossidativoBasso peso alla nascita
Funzione respiratoria nei primi mesi di vita
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Differenti fenotipi di wheezing in età pediatrica e relativa prevalenza
Martinez: Pediatrics 2002;109:362
<3 anni
3-6 anni
>6 anni
Pre
vale
nza
d
i wh
eezi
ng
Wheezing precoce
transitorio
Wheezing non-atopico
Wheezing/asmaIgE-associati
Etá (anni)
R. Cutrera, 2014, cutrera@opbg.net
Fumo passivo - bambini
fumo materno
esposizione in utero
fumo passivo del bambino
tabagismo precoce
dipendenza dal tabacco
adulti fumatori
• Percentuale di fumatori più alta in America (17.5%) e in Europa (17.9%)
• Ragazzi > Ragazze Fumo sigarette in Africa, Sud est Asia e regioni occidentali Pacifico
• Ragazzi > Ragazze Fumo sigarette + altri prodotti del Tabacco
• Suscettibilità Fumo 18.3%. Frequenza maggiore Europa (30.5%),America (24.8%) e più bassa Regioni Pacifico Occidentale (8.3%)
Fumo attivo in età pediatrica
Aumento di tosse frequente Aumento di broncospasmo e
dispnea Decremento dei valori del FEV1
e flussi (reversibile) Diminuzione del rendimento
sportivo dipendenza precoce dalla
nicotina effetto sulla FC e pressione suscettibilità ad infezioni
(immunità e danni ciliari)
Fumo & bambiniperché il pediatra?
il pdf si occupa della salute del bambino
il pdf è a volte l’unico medico della famiglia
il pdf entra nelle case il pdf è ascoltato il pdf deve essere
aiutato
R. Cutrera, 2014 - cutrera@opbg.net
Save the DateXIX Congresso Nazionale
SIMRI
Torino 22 – 24 Ottobre 2015