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Sejal Saglani Clinical Senior Lecturer Respiratory Paediatrics Imperial College London
Outline
Risk factors for exacerbations Predictors of exacerbations in children
Predictors of severe exacerbations
Treatment
Pre-school wheeze Steroids LTRA Magnesium sulphate
Impact of exacerbations Severe exacerbation accelerated lung function decline 30ml/ year greater decline in FEV1 Significant morbidity
Hospitalisation
Fatal
McDonald V & Gibson PG CEA 2010;42:670-7
The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens study (TENOR) 3 year, multi-centre, observational cohort Total n=4756 n=497; 13-17 years, n=770; 6-12 years Severe or difficult-to-treat asthma
Strongest predictors of exacerbation: recent exacerbation history (12 months previously) uncontrolled asthma
Chipps BE JACI 2012 EPub
Good PPV for no hospitalisation (94-99%), but only 70% ability to predict exacerbation
Good PPV low risk of exacerbation predicted Poor NPV Robroeks C et al CEA 2012;42:792-8
Definition Wheeze at discrete times Often with evidence of viral cold NO symptoms in between episodes Wheeze with discrete exacerbations AND symptoms between episodes
Multiple-trigger wheeze
Primary outcome:
Duration of hospitalisation
Secondary outcomes:
Symptom severity & duration Use of beta-agonists
Randomisation
Budesonide neb 1mg bd Montelukast 4mg od Placebo
At onset of RTI for 7 days
Primary outcome
episode free days over 12 months
Secondary outcomes
Symptom severity in 14 days from initiation of therapy Total courses of oral steroids Number of wheezing episodes
Bacharier et al JACI 2008;122:1127-35
Results
Page 22
Secondary outcomes:
Symptoms Use of beta-agonsits Hospitalisations Change in growth & bone mineral density
Page 23
Fluticasone group:
Smaller gain in height and weight
Total budesonide exposure lower in intermittent regimen group (45.7mg) compared to daily regimen group (149.9mg)
Zeiger RS et al NEJM 2011;365:1990-2001
Assessment of viral and bacterial infection with and without acute wheeze
Bisgaard H BMJ 2010
Wheezy episodes associated with both bacterial and viral infection - independently
IV montelukast: Hospitalisation
MgSO4
Single dose IV MgSO4 effective in children when
Poor initial response to inhaled/nebulised bronchodilators Severe exacerbation High risk of admission
Non-invasive ventilation
Advantages Trial in status asthmaticus when conventional management fails CPAP or BiPAP May avoid need for intubation & IPPV Disadvantages Cannot be used with altered mental state
Summary
Prevention and prediction of exacerbations is critical, especially with increasing disease severity - ?vitD supplementation future preventative intervention Important risk factors / predictors Exacerbation in previous year Poor asthma control Synergistic effects of risk factors
Most common infectious precipitants: Viruses (HRV) ?equal role of bacteria in pre-school children Pre-school wheeze Contrasting effects of oral and inhaled steroids intermittent therapy for intermittent symptoms