L`asthme chez l`enfant revisité

L’asthme est la maladie chronique
la plus fréquente chez l’enfant
7 à 10% des enfants scolarisés
sont asthmatiques, soit 2 à 3
enfants par classe de 25 à 30
enfants (1)
Enquête (1999) réalisée auprès de 73.880
familles dans 7 pays européens (2)
28% des enfants asthmatiques
ont leur sommeil perturbé
≥1X/semaine (2)
30% des enfants asthmatiques
ont un retard scolaire de 1 à 3
ans (1)
ASTHME
~ 38% des enfants ont
des symptômes diurnes
1X/semaine (2)
Seulement 5,8% des enfants asthmatiques ont un asthme
parfaitement contrôlé (2)
(1) C. Karila et al. L’enfant asthmatique en milieu scolaire. Archives de pédiatrie 2004; 11:120S-123S
(2) Rabe et al. Clinical management of asthma in 1999: the asthma insights and reality in Europe (AIRE) study. Eur Respir J 2000;16:802-807
Asthme de l’enfant
• Maladie inflammatoire chronique des voies aériennes impliquant
de nombreuses cellules inflammatoires
• Symptômes intermittents de sifflement, de toux nocturne,
d’essoufflement déclenchés par des irritants spécifiques
(allergènes…) ou non spécifiques (stress, effort…)
• Obstruction diffuse ,variable, fixée ou non, réversible
partiellement ou totalement avec ou sans traitement
• Diagnostic clinique avant 5 ans – souvent transitoire (60 % OK à
âge scolaire)
• Traitement des crises+/- traitement de fond
Asthma phenotypes
Phenotype
Allergy
Family
history
Characteristics
Transient/ early
wheezer
-
-
Non-atopic or
viral induced
wheezer
-
-
Atopic wheezer
+
+
Risk factors:
• Intra uterine/postnatal exposure to
tobacco smoke
• Prematurity
• Exposure to siblings, children at day care
center
● Virus induced narrowing (RSV)
● 3-5x more wheeze at age 6
● No increased risk at age 12
● Reversibility at spirometry at 12 years
Protective factors: exposure to:
• Pets/farm animals < age of 1yr
• Siblings
• Children at day care center
Martinez et al.
PRACTALL EAACI / AAAAI Consensus Report
Identification of Asthma Phenotypes Is Critical
Asthma Phenotypes in Children >2 Years of Age
Is the child completely well
between symptomatic periods?
Yes
Are colds the most
common precipitating
factor?
No
No
Is exercise the most
common or only
precipitating factor?
No
Does the child have
clinically relevant
allergic sensitization?
Yes
Yes
Yes
No
Virus-induced
asthmaa
Exercise-induced
asthmaa
Allergen-induced
asthma
Unresolved
asthmaa,b
aChildren
bDifferent
may also be atopic.
etiologies, including irritant exposure and as-yet not evident allergies, may be included here.
Adapted from Bacharier LB, et al. Allergy. 2008;63(1):5–34.
PHYSIOPATHOLOGIE
• anomalies immunologiques
Th1/Th2, interleukines, cell. T régulatrices, cellules dendritiques
(présentent AG aux cell. T)
• atopie
IgEN + symptômes Î 80%
• remodeling
inévitable même si ICS (cfr…)
• inflammation bronchique ~ HBR
• inflammation nasale (adultes > enfant ?)
• cell. Inflammatoires
neutro ++ < inf. virale
< sévérité
éosino ++ < asthme atopique
< symptômes persistants
• obstruction VA (triade classique)
• HBR < asthme,mucoviscidose, inf. virale
mais ++ = sévérité ++
Effet des CSI sur le développement des symptômes
d’asthme et l’évolution de la fonction respiratoire
Proportion of episode-free Days
Etude prospective randomisée en double-aveugle, chez 285 enfants entre 2 et 3 ans avec index prédictif
positif de l'asthme. Observation d’1 an sans traitement après 2 ans sous fluticasone 88µg bid ou placebo.
Critère primaire = proportion de jours sans épisode* au cours de l’année d’observation
P = NS
*Jour sans épisode = pas de symptôme
d'asthme, pas de visite non programmée
auprès d'un médecin pour des symptômes
respiratoires, et pas de recours à des
médicaments supplémentaires contre
l'asthme, y compris l'albutérol avant l'effort.
⇒ “Chez les enfants en âge préscolaire à haut risque d’asthme, 2 ans sous CSI
n’ont pas eu d’effet sur l’apparition de symptômes d’asthme et la dégradation de
la fonction respiratoire pendant une 3ème année sans traitement.”
(5). TW Guilbert et al., NEJM, vol 354, n°19: 1985-1997, 2006
DIAGNOSTIC
= récidive et/ou persistance des symptômes
= follow-up
= ΔΔ (cfr. )
= réponse BD
DIAGNOSTIC (2)
1/ Anamnèse familiale et personnelle (cfr. MAPI)
2/ Histoire clinique
wheezing / toux / effort
(cfr. ΔΔ toux)
3/ Examen clinique
4/ Tac (à répéter 1/an si symptômes persistants)
5/ RAST (eczéma étendu, anti H, choc anaphylactique)
6/ Thorax ( systématique 1 x dans le follow-up)
7/ DEP, spirométrie, oscillations forcées
+ réversibilité FEV1 > 12%
8/ eNO ~ infl. Éosino Æ évaluation du degré
d’inflammation
(4-17 ans)
Æ ICS NP
‘Asthma Predictive Index’
• History of > 3 episodes of wheezing, at least one of which confirmed
by a doctor
and
• one major criteria or 2 or 3 minor criteria
Major criteria:
• One of the parents has asthma
(medical diagnosis)
• Personal antecedents of
diagnosis of atopic dermatitis
• Allergenic sensitisation ≥ 1
aeroallergen
Minor criteria
• Allergic sensitisation to milk,
eggs or peanuts
• Wheezing unrelated to a
respiratory viral disease
• Blood eosinophilia ≥ 4%
Castro-Rodriguez, 2000;Guilbert, 2004
Lack of eosinophilia can predict
remission in wheezy infants ?
Clin Exp Allergy. Mar. 2008 Just J. et al.
•N=219 infants < 30 months
•Reevaluation at the age of 6
Lack of eosinophilia (>470/mm³) : 91%
Lack of eosinophilia + absence of allergic
sensitization : 96.9%
PRACTALL EAACI / AAAAI Consensus Report
Management
Avoidance measures
Pharmacotherapy
Immunotherapy
Education
Adapted from Bacharier LB, et al. Allergy. 2008;63(1):5–34.
PRACTALL EAACI / AAAAI Consensus Report
Avoidance Measures
• Recommended with sensitization and clear association
between allergen exposure and symptoms
Allergen testing (at all ages)
Avoidance of exposure to tobacco smoke
Balanced diet and avoidance of obesity
Exercise should NOT be avoided
Adapted from Bacharier LB, et al. Allergy. 2008;63(1):5–34.
PRACTALL EAACI / AAAAI Consensus Report
Pharmacotherapy Recommendations for
Children 0 to 2 Years
Asthma diagnosis: >3 episodes of reversible bronchial obstruction
within 6 months
Intermittent β2agonists
First choice despite conflicting evidence
LTRA
Daily controller therapy for viral wheezing
(long- or
short-term treatment)
Nebulized or inhaled
corticosteroids
Daily controller therapy for persistent asthmaa
Oral corticosteroidsb
Acute and frequently recurrent obstructive
episodes
First-line treatment when there is evidence
of atopy/allergy
aEspecially
if severe or requiring frequent oral corticosteroid therapy; beg, 1 to 2 mg/kg/day prednisone for 3 to 5 days during acute and
frequently recurrent obstructive episodes.
Adapted from Bacharier LB, et al. Allergy. 2008;63(1):5–34.
PRACTALL EAACI / AAAAI Consensus Report
Step down if
appropriate
Step down if
appropriate
Step Up Therapy to Gain Control
Pharmacologic Treatment (Children >2 Years)
ICS
LTRAa
OR
(Dose depends on age)
(200 µg BDP equivalent)
INSUFFICIENT CONTROLb
Increase ICS dose (400 µg BDP equivalent)
OR
Add ICS to LTRA
INSUFFICIENT CONTROLc
Increase ICS dose (800 µg BDP equivalent)
OR
Add LTRA to ICS
OR
Add LABA
INSUFFICIENT CONTROLc
aLTRA
cCheck
Consider other options
• Theophylline
• Oral corticosteroids
may be particularly useful if the patient has concomitant rhinitis; bCheck compliance, allergy avoidance, and reevaluate diagnosis;
compliance and consider referring to specialist.
ICS=inhaled corticosteroids; LTRA=leukotriene receptor antagonist; BDP=beclomethasone dipropionate; LABA=long-acting β2-agonist.
Adapted from Bacharier LB, et al. Allergy. 2008;63(1):5–34.
PRACTALL EAACI / AAAAI Consensus Report
Immunotherapy Recommendations
•
Requires appropriate allergens for
allergic asthma
•
Use in addition to appropriate environmental
control and pharmacotherapy
•
Not recommended when asthma is unstablea
•
Sensitization to more than 1 allergen not
a contraindicationb
•
Age not an absolute contraindicationc
•
Patients also need to comply with
other treatments
aOn
the day of treatment, patients should have few, if any, symptoms and pulmonary function (FEV1) of at least 80% of the predicted value.
can reduce its efficacy due to the need to limit the allergen dose when several allergens are being administered concurrently.
cCan be used in patients from the age of 3 although this is well below the current licensed age limit.
bBut
Adapted from Bacharier LB, et al. Allergy. 2008;63(1):5–34.
DEVICE adapté à l’âge
PRACTALL EAACI / AAAAI Consensus Report
Education Recommendations
• Affected people
–
–
–
Child
Parents
Caregivers
• Health care professionals
–
–
–
–
Primary care physicians
Nurses
Pharmacists
Health-education workers and
patient support groups
• Health authorities and politicians
Adapted from Bacharier LB, et al. Allergy. 2008;63(1):5–34.
Le “contrôle” est l’objectif
du traitement de l’asthme
Diagnostic
Evaluer
le contrôle
Instaurer un
traitement
initial
Childhood
Asthma
Control Test
(C-ACTTM)
Vérifier
le contrôle*
Adapter
le traitement
* tous les 3-4 mois
Réf. 1: Pocket Guide for asthma management and prevention in Children, GINA revised 2006, www.ginasthma.org
Questions de 1 à 4: à remplir par l’enfant
(sur une échelle de 4 points)
avec l’aide d’un de ses parents1
Questions de 5 à 7: à remplir par le parent
(sur une échelle de 5 points)1
Interprétation du score total
du C-ACTTM
L’asthme de votre enfant est
sans doute bien contrôlé
L’asthme de votre enfant n’est peut-être pas aussi
bien contrôlé qu’il pourrait l’être.
PRACTALL EAACI / AAAAI Consensus Report
Summary of Key Recommendations
9 Identification of asthma phenotype is critical
9 Comprehensive asthma management must include avoidance
measures and education
9 Treatment of airway inflammation leads to optimal asthma
control
9 ICS and LTRAs are recommended as initial controller therapy
for persistent asthma
9 Until further evidence of effectiveness and long-term safety
is available, LABAs should not be used without
an appropriate ICS dose
9 Immunotherapy in addition to environmental control
and pharmacotherapy
Adapted from Bacharier LB, et al. Allergy. 2008;63(1):5–34.
”éduquer”