Scegliere con cura per... l Asma bronchiale

Transcription

1 Scegliere con cura per... l Asma bronchiale Salvatore Cazzato Pneumologia Pediatrica UO Pediatria-Dir. A Pession Azienda Ospedaliero-Universitaria Policlinico S. Orsola-Malpighi Bologna

2 Recurrent episodes of wheeze, cough, and breathlessness, and physiologically by variable airflow obstruction

3 Clinical features that increase the probability of asthma More than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness, particularly if these symptoms: are frequent and recurrent are worse at night and in the early morning occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold or damp air, or with emotions or laughter occur apart from colds Personal history of atopic disorder Family history of atopic disorder and/or asthma History of improvement in symptoms or lung function in response to adequate therapy SIGN 2014

4 < 50% agreement between parents and clinicians reports of wheeze and asthma. It is important to distinguish wheezing a continuous, highpitched musical sound coming from the chest from other respiratory noises, such as stridor or rattly breathing alternative diagnoses

5 until a doctor has heard and documented the presence of true polyphonic (musical) expiratory wheeze, an open mind should be kept about the nature of the sound described. Bush et al. BMJ 2015 Cough variant asthma is a controversial topic. Isolated chronic dry cough in a community setting is rarely if ever due to asthma Wright et al. Am J Respir Crit Care Med not diagnose asthma unless there is a history of considerable breathlessness, as well as either or both of cough and wheeze

6 Features suggestive of a non-asthma diagnosis History Physical examination Presence of prominent upper airway symptoms rhinitis, snoring, and sinusitis Symptoms from the first day of life primary ciliary dyskinesia, aspiration due to incoordinate swallow, congenital lung and airway malformations Sudden onset of symptoms suggestive of foreign body aspiration and requires immediate management. Presence of chronic moist cough or sputum productiony for more weeks and has not resolved with one course of antibiotics, referral is indicated History of systemic illness or suggestive of immunodeficiency: severe, persistent, unusual, or recurrent infections Continuous, unremitting symptoms with no symptomfree days mod. da Bush et al. BMJ 2015

7 Features suggestive of a non-asthma diagnosis History Physical examination Presence of prominent upper airway symptoms rhinitis, snoring, and sinusitis Symptoms from the first day of life primary ciliary dyskinesia, aspiration due to incoordinate swallow, congenital lung and airway malformations Sudden onset of symptoms suggestive of foreign body aspiration and requires immediate management. Presence of chronic moist cough or sputum productiony for more weeks and has not resolved with one course of antibiotics, referral is indicated History of systemic illness or suggestive of immunodeficiency: severe, persistent, unusual, or recurrent infections Continuous, unremitting symptoms with no symptomfree days Systemic signs such as clubbing, weight loss, failure to thrive Upper airway disease tonsillar hypertrophy ect.. Unusually severe chest deformity Unexpected signs on auscultation (fixed monophonic wheeze, stridor, asymmetrical signs) Chest palpation during coughing or forced expiratory manoeuvres palpable secretions revealed Signs of cardiac or systemic disease, such as a cardiac murmur, abnormalities in heart sounds, weight loss, and unusual systemic infections such as pyogenic arthritis or meningitis mod. da Bush et al. BMJ 2015

8 Age-related differential diagnosis for wheezing J Allergy Clin Immunol 2012

9 PARADOXICAL VOCAL FOLD MOVEMENT(VOCAL CORD DYSFUNCTION) VCD is defined by the complete or partial adduction or closure of the vocal folds with inspiration and/or expiration. This maladaptive process is not usually volitional but seems to occur in response to irritation of the larynx or hypopharynx or secondary to emotional or physical stress. Exercise is a common trigger of VCD in extreme or elite athletes, often misdiagnosed as exercise-induced bronchospasm. Asthma and comorbidities. Curr Opin Allergy Clin Immunol 2013, 13:78 86

10 Using child reported respiratory symptoms to diagnose asthma in the community Aims: To study how respiratory symptoms reported by children, with or without spirometry, could help to discriminate those with asthma from those without children (8-12 years) Arch Dis Child 2004;89: Conclusion: Respiratory symptoms, especially wheezing, reported by children had good discriminating ability for asthma in the primary care settings. 42% 18% 83% discriminating ability (PPV + NPV - 100)%. Symptomss FEV1/FVC<75% Symptoms + FEV1/FVC<75% Combining wheezing with an FEV1:FVC ratio<75% gave the highest discriminating ability of 83%.

11 normal results on testing, especially if performed when the child is asymptomatic, do not exclude a diagnosis of asthma Asthma severity not correlate with FEV1 FEV1 is generally normal, even in severe persistent childhood asthma Am J Respir Crit Care Med 2004;

12 an absent response to bronchodilators not exclude asthma a positive BDR test is specific for recent wheeze but is fairly insensitive positive response is much more likely in children with wheeze than in children without wheeze, but about half of the wheezers will be missed. Thorax 2005;60:13 16

13 Bronchodilation and bronchoconstriction: Predictors of future lung function in childhood asthma J Allergy Clin Immunol 2006;117: bronchodilator response may indicate good response to inhaled corticosteroids.

14 A raised FENO is neither a sensitive nor a specific marker of asthma with overlap with children who do not have asthma 429 children Eur Respir J 2005; 25: Distribution of nitric oxide levels in exhaled air (FE,NO) in high-risk ( ) and low-risk ( ) children with (+) and without (-) elevated specific immunoglobulin (Ig)E to inhalant allergens. Children using inhaled corticosteroids were excluded. Bars represent geometric means.

15 A raised FENO is neither a sensitive nor a specific marker of asthma with overlap with children who do not have asthma 429 children Eur Respir J 2005; 25: At present, there is insufficient evidence to support a role for markers of eosinophilic inflammation in the diagnosis of asthma in children. They may have a role in assessing severity of disease or response to treatment. Distribution of nitric oxide levels in exhaled air (FE,NO) in high-risk ( ) and low-risk ( ) children with (+) and without (-) elevated specific immunoglobulin (Ig)E to inhalant allergens. Children using inhaled corticosteroids were excluded. Bars represent geometric means.

16 Positive skin tests increase the probability of asthma in a child with wheeze, particularly in children over five years of age Pediatr Pulmonol. 2005;39:

17 SIGN 2014 British guideline on the management of asthma Conclusioni La diagnosi di asma è clinica valutazione dei sintomi e storia personale e familiare di atopia esclusione accurata di diagnosi alternative Confermata da evidenza di ostruzione variabile al flusso spirometria nella norma non esclude la diagnosi Test allergici (SPT/ IgE specifiche) supporta la diagnosi di asma allergica fenotipi diversi asma non atopica positività si associa a persistenza di asma in età scolare

18

19

20 Tempo necessario per ottenere il controllo dell asma Miglioramento (%) Assenza di sintomi notturni 100 FEV1 PEF del mattino Assenza di uso di farmaco al bisogno Iperreattività components of asthma are sensitive to both the dose and the time of treatment Giorni Settimane Mesi Anni Woolcock. ERS 2000

21 Methods:. Data from a free running test and a methacholine inhalation challenge test were available in 218 children Symptoms+tests Sensitivity Specificity Symptoms symptoms running test Methacholine test Conclusions: Symptom history still forms the basis for defining asthma in clinical setting. BHR tests only marginally increased the diagnostic accuracy after symptom history had been taken into account.