Il wheezing prescolareAbbiamo sbagliato

bambino?

Renato CutreraDir. U.O.C. Broncopneumologia

Dipartimento Medicina Pediatrica (Prof. A.G. Ugazio)Ospedale Pediatrico Bambino Gesù IRCCS - Roma

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Salerno PediatriaIl Bambino cresce

Vietri sul mare 29 Novembre 2014

25 %25 %R. Cutrera, 2014, cutrera@opbg.net 2

mm

Allora è asmatica?

mm

Ha di nuovo qualche fischio

Wheezing ricorrente

Il dilemma

R. Cutrera, 2014, cutrera@opbg.net 3

4R. Cutrera, 2014, cutrera@opbg.net

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Asthma and Wheezing in the First Six Years of LifeFernando D. Martinez, et al. (N Engl J Med. 1995;332:133-8.)

No wheezing51%

Transient early

wheezing20%

Late onset wheezing

15%

Persistent wheezing

14%

1246 neonati seguiti fino ai 3 anni e ai 6 anni di vita (826)

Nel 1° anno di vitaIgE cordone (n.750)PFT a < 6 m (n.125)IgE seriche 9m (n.672 A1 anno di vita Questionario (n.800) Primi 3 anni follow-up per patologia basse vie aeree (n.888) A 6 anni di vita questionario sul wheezing (n.1024) A 6 anni di vitaIgE seriche (n.460)PFT (n.526)Skin Tests (n.629)

Tutto iniziò da .. Tucson (almeno per noi pediatri)

R. Cutrera, 2014, cutrera@opbg.net

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Livelli di IgE seriche e prevalenza di positività cutanea ad allergeni inalanti in

relazione al tipo di wheezing.

0

10

20

30

40

50

60

70

Serum IgE(IU/ml)

Positive skintest (%)

No wheezing

Transient earlywheezing

Late onsetwheezing

Persistent wheezing

* p <0.01 ** p <0.001 *** p = 0.003

***

***

Asthma and Wheezing in the First Six Years of LifeFernando D. Martinez, et al. (N Engl J Med. 1995;332:133-8.)

R. Cutrera, 2014, cutrera@opbg.net

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950

1000

1050

1100

1150

1200

1250

1300

6 years

ml/s

No wheezing

Transient earlywheezing

Late onsetwheezing

Persistentwheezing

0

20

40

60

80

100

120

140

< 1 year

ml/

s **

*

Asthma and Wheezing in the First Six Years of LifeFernando D. Martinez, et al. (N Engl J Med. 1995;332:133-8.)

*p <0.01

VmaxFRC durante il 1° anno di vita e a 6 anniin funzione della storia di wheezing.

R. Cutrera, 2014, cutrera@opbg.net

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Differenti fenotipi di wheezing in età pediatrica e relativa prevalenza

Martinez: Pediatrics 2002;109:362

<3 anni

3-6 anni

>6 anni

Pre

vale

nza

d

i wh

eezi

ng

Wheezing precoce

transitorio

Wheezing non-atopico

Wheezing/asmaIgE-associati

Etá (anni)

R. Cutrera, 2014, cutrera@opbg.net

Fenotipi basati sul pattern dei sintomi

Brand P et al. Eur Respir J 2014; 43: 1172–1177

R. Cutrera, 2014, cutrera@opbg.net 10

Eur Respir J 2014; 43: 1172–1177

Post-hoc analysis on data obtained in 166 pre-school children with multiple-trigger wheezing, recruited during an acute wheezing episode.

Compare the efficacy of one week treatment with 400 μg b.i.d. nebulized beclomethasone dipropionate (BDP), plus nebulized 2500 μg prn salbutamol (BDP group), versus nebulized b.i.d. placebo, plus nebulized prn 2500 μg salbutamol (placebo group)

Post-hoc analysis on data obtained in 166 pre-school children with multiple-trigger wheezing, recruited during an acute wheezing episode.

Compare the efficacy of one week treatment with 400 μg b.i.d. nebulized beclomethasone dipropionate (BDP), plus nebulized 2500 μg prn salbutamol (BDP group), versus nebulized b.i.d. placebo, plus nebulized prn 2500 μg salbutamol (placebo group)

Short term efficacy of nebulized beclomethasone in mild-to-moderate wheezingepisodes in pre-school children. Papi A, Nicolini G, Boner AL, Baraldi E, Cutrera R, Fabbri LM, Rossi GA. Ital J Pediatr. 2011 Aug

22;37:39.

Short term efficacy of nebulized beclomethasone in mild-to-moderate wheezingepisodes in pre-school children. Papi A, Nicolini G, Boner AL, Baraldi E, Cutrera R, Fabbri LM, Rossi GA. Ital J Pediatr. 2011 Aug

22;37:39.

Mean coughing score in the first week of treatment; each day represents the cumulative mean coughing score; * p < 0,05 between groups.

Mean coughing score in the first week of treatment; each day represents the cumulative mean coughing score; * p < 0,05 between groups.

Short term efficacy of nebulized beclomethasone in mild-to-moderate wheezingepisodes in pre-school children. Papi A, Nicolini G, Boner AL, Baraldi E, Cutrera R, Fabbri LM, Rossi GA. Ital J Pediatr. 2011 Aug

22;37:39.

Short term efficacy of nebulized beclomethasone in mild-to-moderate wheezingepisodes in pre-school children. Papi A, Nicolini G, Boner AL, Baraldi E, Cutrera R, Fabbri LM, Rossi GA. Ital J Pediatr. 2011 Aug

22;37:39.

Percentage of symptom-free days in the first week of treatment; on day 1 the data is relative to the % of symptom-free patients; * p < 0.05 between groups.

Percentage of symptom-free days in the first week of treatment; on day 1 the data is relative to the % of symptom-free patients; * p < 0.05 between groups.

The percentage of SFDs was significantly higher in the BDP group (54.7%) than in the placebo group (40.5%; p = 0.012), with a 35% relative difference. There were no differences in positive effects of BDP treatment between children with and without risk factors for asthma.

The percentage of SFDs was significantly higher in the BDP group (54.7%) than in the placebo group (40.5%; p = 0.012), with a 35% relative difference. There were no differences in positive effects of BDP treatment between children with and without risk factors for asthma.

CONCLUSIONS:

A 1-week treatment with nebulized BDP and prn salbutamol is effective in increasing SFDs and improving cough in children with wheezing, providing a clinical rationale for the short term use of ICS in episodic wheeze exacerbations in pre-school children.

CONCLUSIONS:

A 1-week treatment with nebulized BDP and prn salbutamol is effective in increasing SFDs and improving cough in children with wheezing, providing a clinical rationale for the short term use of ICS in episodic wheeze exacerbations in pre-school children.

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Long-Term Inhaled Corticosteroids in Preschool Children at High Risk for Asthma – Prevention of Early Asthma in

Kids (PEAK) clinical trialTheresa W. Guilbert et al. N Engl J Med 2006;354:1985-97.

R. Cutrera, 2014, cutrera@opbg.net

R. Cutrera, 2014, cutrera@opbg.net

Model of changes of lung function in healthy subjects

Fletcher & Peto BMJ 1977Vita FetaleInfezioni

Asma/allergiaFumo di tabacco

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R. Cutrera, 2014, cutrera@opbg.net 16

Vita FetaleInfezioniAsma/allergiaFumo di tabacco ?

Model of changes of lung function in healthy subjects

Fletcher & Peto BMJ 1977

R. Cutrera, 2014, cutrera@opbg.net

64 million people COPD worldwide in 2004 (WHO)

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R. Cutrera, 2014, cutrera@opbg.net18

R. Cutrera, 2014, cutrera@opbg.net

00

0.50.5

1.01.0

1.51.5

2.02.0

2.52.5

3.03.0Proportion of 1965 Rate (USA)Proportion of 1965 Rate (USA)

1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998

–59%–59% –64%–64% –35%–35% +163%+163% –7%–7%

CoronaryHeart

Disease

CoronaryHeart

Disease

StrokeStroke Other CVDOther CVD COPDCOPD All OtherCauses

All OtherCauses

More than 3 million people died of COPD in 2005, which is equal to 5% of all deaths globally that

year19

R. Cutrera, 2014, cutrera@opbg.net 20

R. Cutrera, 2014, cutrera@opbg.net

COPD - FATTORI DI RISCHIO

Fattori ambientaliFumo di sigaretta

Fumo passivoFumo materno

Inquinamento outdoor, indoorEsposizione professionale

Crescita del polmoneNutrizione

Infezioni respiratorie

Fattori individualiDeficit alfa1-AT

Stress ossidativoBasso peso alla nascita

Funzione respiratoria nei primi mesi di vita

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Differenti fenotipi di wheezing in età pediatrica e relativa prevalenza

Martinez: Pediatrics 2002;109:362

<3 anni

3-6 anni

>6 anni

Pre

vale

nza

d

i wh

eezi

ng

Wheezing precoce

transitorio

Wheezing non-atopico

Wheezing/asmaIgE-associati

Etá (anni)

R. Cutrera, 2014, cutrera@opbg.net

Fumo passivo - bambini

fumo materno

esposizione in utero

fumo passivo del bambino

tabagismo precoce

dipendenza dal tabacco

adulti fumatori

• Percentuale di fumatori più alta in America (17.5%) e in Europa (17.9%)

• Ragazzi > Ragazze Fumo sigarette in Africa, Sud est Asia e regioni occidentali Pacifico

• Ragazzi > Ragazze Fumo sigarette + altri prodotti del Tabacco

• Suscettibilità Fumo 18.3%. Frequenza maggiore Europa (30.5%),America (24.8%) e più bassa Regioni Pacifico Occidentale (8.3%)

Fumo attivo in età pediatrica

Aumento di tosse frequente Aumento di broncospasmo e

dispnea Decremento dei valori del FEV1

e flussi (reversibile) Diminuzione del rendimento

sportivo dipendenza precoce dalla

nicotina effetto sulla FC e pressione suscettibilità ad infezioni

(immunità e danni ciliari)

Fumo & bambiniperché il pediatra?

il pdf si occupa della salute del bambino

il pdf è a volte l’unico medico della famiglia

il pdf entra nelle case il pdf è ascoltato il pdf deve essere

aiutato

R. Cutrera, 2014 - cutrera@opbg.net

Save the DateXIX Congresso Nazionale

SIMRI

Torino 22 – 24 Ottobre 2015