GINA Guidelines : particularités pédiatriques

Dr G de Bilderling

Pneumologie pédiatrique

CHR Namur

Prevalence increasing in many countries, Prevalence increasing in many countries, especially in childrenespecially in children

Factors that Exacerbate Asthma :Factors that Exacerbate Asthma :Viral infections +++Viral infections +++

Asthma DiagnosisAsthma DiagnosisSpirometry > 6ySpirometry > 6yMeasurements of allergic statusMeasurements of allergic status

Asthmatic phenotypes

Martinez J Allergy Clin Immunol 2003;111:661- 75

Pronostic 1

Modified Asthma Predictive Index

< 3 years and recurrent wheezing episodes

2 criteria :

• allergic rhinitis

• Wheezing episodes not associated with URTI

• Eosinophilia

75% of these children will have active asthma

••

1 criteria :

•Parental asthma

•Atopic dermatitis

or

and

Castro-Rodriguez AJRCCM 2000;162: 1403 -1406 Pronostic 7

• Aeroallergern sensitization

SUMMARY OF SUMMARY OF

STEPWISE STEPWISE

MANAGEMENT IN MANAGEMENT IN

CHILDREN LESS CHILDREN LESS

THAN THAN

5 YEARS5 YEARS

British guidelines on the management of asthma. Thorax 2003, 58

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by AgeEstimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

Beclomethasone Beclomethasone 200-500 100-200 200-500 100-200 >500-1000 >200-400>500-1000 >200-400 >1000 >400>1000 >400

BudesonideBudesonide 200-600 100-200-600 100-200200

600-1000 >200-400600-1000 >200-400 >1000 >400>1000 >400

Budesonide-Neb Budesonide-Neb Inhalation SuspensionInhalation Suspension

250-250-500500

>500->500-10001000

>1000>1000

CiclesonideCiclesonide 80 – 160 80-16080 – 160 80-160 >160-320 >160-320 >160-320 >160-320 >320-1280 >320>320-1280 >320

FlunisolideFlunisolide 500-1000 500-500-1000 500-750750

>1000-2000 >750-1250>1000-2000 >750-1250 >2000 >1250>2000 >1250

FluticasoneFluticasone 100-250 100-100-250 100-200200

>250-500 >200-500>250-500 >200-500 >500 >500>500 >500

Mometasone furoateMometasone furoate 200-400 100-200-400 100-200200

> 400-800 >200-400> 400-800 >200-400 >800-1200 >400>800-1200 >400

Triamcinolone acetonideTriamcinolone acetonide 400-1000 400-400-1000 400-800800

>1000-2000 >800-1200>1000-2000 >800-1200 >2000 >1200>2000 >1200

Survey of adrenal crisis associated with inhaled Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdomcorticosteroids in the United Kingdom

Todd GRG, Acerini CL, Ross-Russel R, Zahra S, Warber JT, Todd GRG, Acerini CL, Ross-Russel R, Zahra S, Warber JT, McCance D.McCance D.

Arch Dis Child 2002; 87: 457-461.Arch Dis Child 2002; 87: 457-461.

ChildrenChildren AdultsAdults Males/females (n)Males/females (n) 17/1117/11 3/2 3/2 Mean age (yrs) :Mean age (yrs) : 6.4 (3.3-10)6.4 (3.3-10) 41 (18-80)41 (18-80) Presentation (n) :Presentation (n) :

Acute hypoglycaemiaAcute hypoglycaemia 2323 11 Decreased consiousness/comaDecreased consiousness/coma1313 00 Coma and convulsionsComa and convulsions 1010 11

( Death( Death : : pneumococcal septicaemia)pneumococcal septicaemia) 11

InsidiousInsidious 55 44

Duration of ICS R/ (yrs)Duration of ICS R/ (yrs) 1.7 (n = 22)1.7 (n = 22) 3.3 (n = 4)3.3 (n = 4) Mean dose of FP Mean dose of FP 980980 1380 1380

in µg/day (range) in µg/day (range) (500-2000)(500-2000) (1000-(1000-2000 2000

Age-related devicesAge-related devices

Age First choice Second choise

0-2 MDI+spacer, facemask

Nebulisations

3-6 MDI+spacer Nebulisations

6-12 (SABA)

MDI+spacer, Breath actuated, DPI

-

6-12 (chronic)

MDI+spacer DPI

12+ (SABA)

Breath actuated, DPI

-

12+ (chronic)

MDI+spacer DPI, breath actuated

Exacerbation

MDI+spacer Nebulisations

Aérosols doseurs : UTILISATION INCORRECTEDeux asthmatiques sur trois utilisent mal les aérosols*Deux asthmatiques sur trois utilisent mal les aérosols*

1 - secouer préalablement avant l’usage 2 - débuter l ’inspiration avant d’activer l’inhalateur 3 - inhaler doucement et profondément 4 - activer l’inhalateur en une seule fois 5 - retenir sa respiration 5 sec ou + après inhalation

technique optimale

72 6458 6278 6867 8260 55

22 20

fréquence d’usage correct des inhalateurs (%) adultes enfants

* résultats d’une enquête INSERM sur 768 patients adultes et enfants

Young children are more difficult to Young children are more difficult to diagnose.diagnose.

Treatment (inhalation device) must be Treatment (inhalation device) must be adapted to age.adapted to age.

Partnership is even more important in this Partnership is even more important in this age-group.age-group.

Young children are more difficult to Young children are more difficult to diagnose.diagnose.

Treatment (inhalation device) must be Treatment (inhalation device) must be adapted to age.adapted to age.

Partnership is even more important in this Partnership is even more important in this age-group.age-group.

Asthma Management and Prevention Asthma Management and Prevention Program:Program: SummarySummaryAsthma Management and Prevention Asthma Management and Prevention Program:Program: SummarySummary