Genova 28 gennaio 2017 SIP

Un lattante che fischia: asma, wheezing, bronchiolite o...?

Cosa facciamo sul territorio?

SerenaPanigadaU.O.PediatriaadIndirizzo

PneumoallergologicoIRCCSG.Gaslini

eGiovanniSempriniPediatradiFamiglia

Genova

Continuitàassistenzialetraospedaleeterritorio

nella bronchiolite

Bronchiolite: malattia dalle molte problematiche che può mettere in seria difficoltà

1) Non abbiamo terapia domiciliare efficace e validata scientificamente

2) Una storia naturale che può rapidamente evolvere verso la gravità e spaventare molto i genitori

3) Patologia che insorge nei primi mesi di vita, spesso prima che si sia instaurato un buon rapporto di fiducia

2013

Al pediatra viene sempre richiesto un intervento terapeutico!, difficile convincere le famiglie ad usare solo acqua fresca o al limite un po’ più salata

Quindi è possibile riuscire a convincere i colleghi a non usare , antibiotici, cortisonici topici o sistemici?

E come fare a non ricoverare tutti i pazientini che sibilano un po’?

2013

Lancet Volume 389, No. 10065, p128, 14 January 2017. Clinical guidance for bronchiolitis

The UK National Health Service and health-care providers across the northern hemisphere are under unprecedented pressure this month, which coincides with peak season for respiratory infections.

Symptom profiles vary from mild to extremely serious, rendering diagnosis of the condition and prognosis challenging. The variation in progression and severitybetween patients requires constant attention and can be terrifying for parents of young patients.

Diagnosis is mainly clinical since diagnostic tests are often inaccurate

One key problem is the range of clinical guidelines and the few treatment options for halting progression of the disease.

Lancet Volume 389, No. 10065, p128, 14 January 2017. Clinical guidance for bronchiolitis

� Systematic reviews have shown no functional benefit when patients are treated with bronchodilators, nebulised hypertonic saline, or corticosteroids, and treatment with high-flow oxygen is contentious since there is disagreement as to the saturation of oxygen required for benefit.

� Physicians are under pressure by parents to medicate and, although the cause of bronchiolitis is viral, physicians often prescribe antibiotics despite there being no clinical evidence for improvement and the increased risk of antimicrobial resistance and adverse events.

With no consensus on clinical management or pathway for treatment, there is a need for more research

Lancet Volume 389, No. 10065, p128, 14 January 2017. Clinical guidance for bronchiolitis

The classic clinical presentation of bronchiolitisstarts with symptoms of a viral upper respiratoryinfection, such as nasal discharge, that progress to the lower respiratory tract over several days.

Timing of symptom progression can vary, and young infants can present with apnoea.

Lower respiratory tract symptoms of bronchiolitisinclude persistent cough, tachypnoea, and increased work of breathing, as shown by intercostal or supraclavicular retractions, use of abdominal muscles, grunting, or nasal flaring. .

Lancet viral Bronchiolitis : Storia Naturale

� Auscultatory findings include crackles and wheeze

� A hallmark characteristic of bronchiolitis is the minute-to-minute variation in clinical findings, asmucus and debris in the airways are cleared by coughing or as the child’s state changes from sleepto agitation.

� This variation can confound assessment, and oftenrequires several examinations over a period of observation.

Lancet viral Bronchiolitis : Storia Naturale

� Nasal congestion can also confound the clinicalassessment

� Nasal suctioning might help to ascertain whichfindings are truly from the lower airways.

� Fever can be present in about a third of infants with bronchiolitis, but it is usually present early in the illness with a temperature less than 39°C.

� The median duration of symptoms is about 2 weeks, with 10–20% of infants still havingsymptoms at 3 weeks after onset.

Lancet viral Bronchiolitis : Storia Naturale

Score clinici� Various clinical scores have been shown in studies

and clinical protocols to correlate with diseaseseverity and improvement.

� Although documentation of a score can be usefulas an objective measure, individual scores are nothighly predictive, and they should be repeated and combined with other measures of severity for a universal assessment to guide decision making.

Diagnosi differenziale� The differential diagnosis for bronchiolitis includes

considerations of various infectious and non-infectious causes.

� Absence of upper respiratory symptoms shouldraise suspicion of other causes of respiratorydistress in young infants, including cardiac disease, congenital airway abnormalities such as a vascularring, or foreign body aspiration.

Diagnosi differenziale� Other infections can resemble or complicate

bronchiolitis.

� Pertussis should be considered in infants with severe or paroxysmal cough, or with knownexposure.

� Bacterial infections complicating viral bronchiolitis, including otitis media or pneumonia, might presentas a new fever or worsening status later in the course of illness.

Fattori di rischio� Various risk factors have been associated with

progression to severe bronchiolitis. Those supported by the strongest evidence include presence of chronic lungdisease of prematurity and haemodynamically importantcongenital heart disease, with immunodeficiency and neuromuscular disorders also considered as high risk in practice guidelines.

� Young infants (aged <2–3 months) and those with a history of premature birth (especially <32 weeks’ gestation) are also at high risk for progression and can present with apnoea without other clinical findings.

Esami diagnostici?

� Bronchiolitis is a clinical diagnosis based on historyand physical examination, according to consensusacross national guidelines.

� For infants with a typical presentation of bronchiolitis, routine imaging or laboratory testing isnot recommended, as they increase costs withoutevidence for benefit .

saturimetria� Appropriate use of pulse oximetry monitoring and

initiation of oxygen for bronchiolitis have receivedincreasing attention in studies and practiceguidelines

� They play an important role in the decision to admitinfants with bronchiolitis to hospital and in the length of their hospital stay.

saturimetriaThe Journal of Pediatrics

Pulse oximetry based decisions increase hospitalization in bronchiolitis . Anne M. Gadomski, MD, MPH

� Forty-four of 108 patients (41%) in the true oximetrygroup and 26 of 105 (25%) in the altered oximetrygroup were hospitalized within 72 hours, numberneeded to harm (NNH) 7 (95% confidence interval (4 to 29).

� There was no difference in subsequent unscheduledvisits for bronchiolitis between the 2 groups.

Ora 2 diapositive dal 2013, poi mi direte cosa è cambiato?

Altro problema che pone la Bronchiolite, fino a dove arriva la Potestà di Curare? Siamo, come spesso in medicina, in zona grigia?

L’ Adrenalina è un vero farmaco, potente, che nella nostra esperienza può cambiare rapidamente la situazione, ma se ho effetti collaterali gravi?Pediatrics 1999;Ziegler Manish J. Butte, Bac X. Nguyen, Tim J. Hutchison, James W. Wiggins and James W.Pediatric Myocardial Infarction After Racemic Epinephrine Administration

J Trop Pediatr. 2011 Dec;Life-threatening cardiac arrhythmia after a single dose of nebulizedepinephrine in pediatric emergency department.Toaimah FH, Al-Ansari K.

2013

Ma sono solo casi anedottici ? Cosa dice la letteratura

Safety of nebulization with adrenaline . Zhang L & Sanguebcshe LS Jornal de Pediatria - Vol. 81, No.3, 2005

Se l’adrenalina puo portare ad effettiavversi pericolosi, Il salbutamolo è più sicuro?

J Pediatr Pharmacol Ther. 2012 Jan;17(1):93-7. doi: 10.5863/1551-6776-17.1.93.Probable association of tachyarrhythmia with nebulized albuterol in a child with previously subclinical wolff Parkinson white syndrome.Kroesen M, Maseland M, Smal J, Reimer A, van Setten P.

Franklin WH, Dietrich AM, Hickey RW, Brookens MA. Department of Pediatrics, Ohio State University, Columbus. Pediatr Emerg Care. 1992 Dec;8(6):338-41.Anomalous left coronary artery masquerading as infantile bronchiolitis.

2013

Legge Balduzzi e DdL Bianco Gelli sulla responsabilità professionale

Bronchodilators for bronchiolitis (Review)Copyright © 2014 The Cochrane Collaboration.

AUTHORS’ CONCLUSIONS Implications for practiceGiven their high cost, adverse effects and lack of effect on oxy-gen saturation and other outcomes included in this meta-analysis,bronchodilators are not effective in the routine management of first-time wheezers who present with the clinical findings of bronchiolitis, in either inpatient or outpatient settings.

Bronchodilators for bronchiolitis (Review)Copyright © 2014 The Cochrane Collaboration.

Implications for research

Prior to conducting further treatment trials, an objective outcome measurethat correlates with pulmonary function tests and is independent of the levelof alertness of the infant needs to be developed and validated. Measures such as need for hospital admission and duration of hospital stay, while important from a health service utilization perspective, may not be adequately sensitive to measure the improvement that may occur from treatment (Hall 2004; Hall 2007).

Pulmonary function testing outcomes should be standardized so thatoutcome data can be merged across studies.

Treatment trials need to be conducted using placebo controls. RCTs with large sample size and standardized methodology across clinical sites are needed to answer completely the question of efficacy. Exclusion criteria must be consistently applied to exclude infants with recurrent wheezing, asthma or other pulmonary disease.

Siamo in terreno pericoloso quale è la cordache ci può far arrivare in cima in sicurezza?

Un Protocollo condiviso ospedale territorio!Cosi elaborammo nel 2003 uno score clinico per valutarela gravità clinica e un protocollo terapeutico

2003

2003

Ovviamente si consiglia un uso giudizioso della adrenalina !!

Quali sono i casi in cui, alla luce della nostra esperienza , sembrerebbe indicata negli outpatient?

Forme iniziali lievi o medie in cui l’”organizzazione” della malattia non ha ancora raggiunto il punto di non ritorno.

La prima somministrazione deve essere somministrata sotto supervisione medica e solo se efficace continuata , più che ad orario fisso on-demand come sembra dimostrare il recente lavoro di Skjerven Racemic adrenaline and inhalation strategies in acute bronchiolitis. N Engl J Med. 2013 Jun 13

Forme gravi in cui si cerca di stabilizzare il paziente in attesa del 118.

2013

conclusioni

� With no consensus on clinical management or pathway for treatment, there is a need for more research

� Quindi?

conclusioni� La Bronchiolite è una delle prime cause di ricovero

nei primi anni di vita

� In italia abbiamo come pochi altri paesi al mondo un servizio pediatrico diffuso nel territorio

� Abbiamo bisogno di validare una pratica (Il Trattamento precoce con adrenalina in Fase iniziale di malattia) che empiricamente si è dimostrata efficace nell’interrompere la progressione di malattia.