GINA Guidelines particularits pdiatriques Dr G de Bilderling

GINA Guidelines : particularités pédiatriques Dr G de Bilderling Pneumologie pédiatrique CHR Namur

Prevalence increasing in many countries, especially in children l Factors that Exacerbate Asthma : l Viral infections +++ l Asthma Diagnosis l Spirometry > 6 y l Measurements of allergic status

Asthmatic phenotypes Martinez Pronostic 1 J Allergy Clin Immunol 2003; 111: 661 - 75

Modified Asthma Predictive Index < 3 years and recurrent wheezing episodes and 1 criteria : • Parental asthma • Atopic dermatitis or • Aeroallergern sensitization 2 criteria : • allergic rhinitis • Wheezing episodes not associated with URTI • Eosinophilia 75% of these children will have active asthma Castro-Rodriguez AJRCCM 2000; 162: 1403 -1406 Pronostic 7

SUMMARY OF STEPWISE MANAGEMENT IN CHILDREN LESS THAN 5 YEARS British guidelines on the management of asthma. Thorax 2003, 58

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age Drug Low Daily Dose ( g) > 5 y Age < 5 y Medium Daily Dose ( g) > 5 y Age < 5 y Beclomethasone 200 -500 100 -200 >500 -1000 >200 -400 Budesonide 200 -600 100 -200 600 -1000 >200 -400 Budesonide-Neb Inhalation Suspension Ciclesonide 250 -500 80 – 160 80 -160 High Daily Dose ( g) > 5 y Age < 5 y >1000 >500 -1000 >160 -320 Flunisolide 500 -1000 500 -750 >1000 -2000 Fluticasone 100 -250 100 -200 >250 -500 Mometasone furoate 200 -400 100 -200 > 400 -800 Triamcinolone acetonide 400 -1000 400 -800 >1000 -2000 >400 >1000 >160 -320 >320 -1280 >750 -1250 >2000 >1250 >200 -500 >500 >200 -400 >800 -1200 >2000 >320 >400 >1200

Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom Todd GRG, Acerini CL, Ross-Russel R, Zahra S, Warber JT, Mc. Cance D. Arch Dis Child 2002; 87: 457 -461. Children Adults 17/11 6. 4 (3. 3 -10) 3/2 41 (18 -80) 23 1 l Decreased consiousness/coma 13 0 1 Males/females (n) l Mean age (yrs) : l Presentation (n) : l l Acute hypoglycaemia l Coma and convulsions 10 ( Death : pneumococcal septicaemia) 1 l Insidious Duration of ICS R/ (yrs) l Mean dose of FP in µg/day (range) l 5 4 1. 7 (n = 22) 980 (500 -2000) 3. 3 (n = 4) 1380 (1000 -2000

Age-related devices Age First choice Second choise 0 -2 MDI+spacer, facemask MDI+spacer Nebulisations 3 -6 Nebulisations 6 -12 (SABA) MDI+spacer, Breath actuated, DPI 6 -12 MDI+spacer (chronic) - 12+ (SABA) - Breath actuated, DPI MDI+spacer 12+ (chronic) Exacerbation MDI+spacer DPI, breath actuated Nebulisations

Aérosols doseurs : UTILISATION INCORRECTE Deux asthmatiques sur trois utilisent mal les aérosols* fréquence d’usage correct des inhalateurs (%) adultes enfants 72 64 1 - secouer préalablement avant l’usage 58 62 2 - débuter l ’inspiration avant d’activer l’inhalateur 78 68 3 - inhaler doucement et profondément 67 82 4 - activer l’inhalateur en une seule fois 60 55 5 - retenir sa respiration 5 sec ou + après inhalation technique optimale 22 20 * résultats d’une enquête INSERM sur 768 patients adultes et enfants

Asthma Management and Prevention Program: Summary l Young children are more difficult to diagnose. l Treatment (inhalation device) must be adapted to age. l Partnership is even more important in this age-group.