Novit  nella Terapia delle Malattie Respiratorie Novembre 2014

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Transcript of Novit  nella Terapia delle Malattie Respiratorie Novembre 2014

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Novit nella Terapia delle Malattie Respiratorie Novembre 2014 Slide 2 Novit nella Terapia delle Malattie Respiratorie Wheezing prescolare Tosse Infezioni Wheezing prescolare Slide 3 Wheezing episodico virale Wheezing da fattori multipli Mantenimento consigliato sempre un trial terapeutico, sospendere se inefficace Antileucotrienico, oppure CSI, oppure CSI + antileucotrienico Antileucotrienico, oppure CSI, oppure CSI + antileucotrienico CSI (es. beclometasone equivalente 400 g/die per 3 mesi) se sintomi persistenti: CSI + antileucotrienico CSI (es. beclometasone equivalente 400 g/die per 3 mesi) se sintomi persistenti: CSI + antileucotrienico Wheezing in et prescolare: terapia 2013 PROGETTO LIBRA www.ginasma.it Brand Eur Respir J. 2014 Slide 4 OR for long-term ICS and/or leukotriene modifiers prescription 7.1 2.22.7 8.5 Frequent wheeze ED visits Personal allergy Day-care diseases attendance 8 7 6 5 4 3 2 1 0 Terapia di mantenimento nel wheezing prescolare: in base a cosa decidere? Terapia di mantenimento nel wheezing prescolare: in base a cosa decidere? What drives prescribing of asthma medication to preschool wheezing children? Montella, Pediatr Pulmonol 2013 376 pts (32.8 mo) with wheezing ( 54% frequent wheeze: 4 episodes/yr) Slide 5 77% 23% Frequenza e severit dei sintomi sono i principali determinanti nella decisione dei pediatri di libera scelta di trattare o non trattare a lungo termine p < 0.05 p = NS 23% 77% What drives prescribing of asthma medication to preschool wheezing children? Montella, Pediatr Pulmonol 2013 Slide 6 Eur Respir J. 2014 Slide 7 Slide 8 Novit nella Terapia delle Malattie Respiratorie Tosse Slide 9 Duration of symptoms of respiratory tract infections in children: systematic review. Thompson, BMJ. 2013 Days Resolution of acute cough in 50% of ch. at 10 days 10%: cough at 25 days 50 % 10 Slide 10 Starting point for treatment of cough: Medical History Acute (< 3 wks) Recurrent acute ( 2/yr; 7-14 days) Chronic (> 8 wks) Prolonged acute (subacute; 3-8 wks) Marais, ADC 2005 ACUTE and SUB-ACUTE CHRONIC RECURRENT Therapy for cough should be directed at the aetiology and specific treatments used where possible Chung, Pulm Pharmacol Ther 2002 Slide 11 ACUTE COUGH Foreign Body urgent rigid bronchoscopy HOW TO TREAT? EZIOLOGIA specifica se ne chiaramente identificabile la causa (ad es. se associata a caratteristiche suggestive di una patologia polmonare o sistemica) non specifica quando isolata, senza evidenza di altri sintomi respiratori ed associata a rx- torace nella norma Shields, Thorax 2008 Respiratory tract infection Non Specific Cough. Slide 12 Honey, Dextromethorphan (DM), and No Treatment on Nocturnal Cough for Coughing children and Their Parents. Paul, Arch Pediatr Adolesc Med 2007 Honey may be preferable for cough and sleep difficulty in URTI 105 ch. with URTI & night cough Cough frequency First night Second night p Treating cough and cold: Guidance for caregivers of children and youth. Goldman, Paediatr Child Health 2011 Fluid intake Mainstay of therapy Humidified air, Echinacea, Zinc, Vitamin C Frequently used, not recommended Non steroidal anti-inflammatory drugs Not significantly reduce symptom score/duration may affect discomfort caused by the viral illness Antihistamines No clinically significant effect Honey Pasteurized honey safe in > 1 yr Demulcent/antioxidant/antimicrobial effects/increases cytokines Slide 14 2010 Azione antiossidante antiinfiammatoria anestetica antinfettiva Slide 15 Mucolitici Controindicazione in et < 2 aa (aumento di tosse/muco, dispnea, vomito) * Per et > 2 aa, l'uso di un mucolitico possibile, ma non va continuato in caso di persistenza o peggioramento dei sintomi. Alcune significative misure in grado di dar sollievo: Far dormire in posizione supina, con la testa sollevata Far bere il bambino frequentemente Tenere fresca la stanza Non fumare in casa, anche al di fuori della camera Acetilcisteina, carbocisteina, ambroxolo, bromexina, sobrerolo, neltenexina, erdosteina, telmesteina * Farmaci uso rettale con derivati terpenici (es, canfora, timo, terpineolo, mentolo, olii di aghi di pino, eucalipto e trementina): NO < 30 mesi e se epilessia/conv. febbrili) Novembre 2010 Mucolitici per uso orale/rettale Slide 16 Upper Airway Cough Syndrome (UACS) in Children Includes various types of rhinosinus diseases that induce cough (allergic/nonallergic rhinosinusitis; tonsillar hypertrophy) Antihistamines/ nasal steroids + allergen avoidance (= allergic rhinitis) Resolution can take up to 2- 4 wks of therapy Goldsobel, J Pediatr 2010 PROLONGED ACUTE ( SUBACUTE ) COUGH 3-8 wks Slide 17 Chest 2006 Thorax 2008 CHRONIC COUGH Chronic sinus disease? Protracted Bacterial Bronchitis? SPECIFIC COUGH Slide 18 Protracted Bacterial Bronchitis in which patients? Preschool healthy children with significant viral LRT infections H. influenzae S. pneumoniae M. catarrhalis P. aeruginosa Priftis, Chest 2013 Chronic wet cough 4 wks in the absence of other diagnoses Persistent symptoms + intermittent exacerbations Impairment of host defenses and impaired mucociliary clearance CILIA CHANGES RECOVERY AFTER MANY WEEKS CHEST IMAGING Normal lung (30%) Bronchial wall thickening (48%) Increased bronchial markings (20%) Consolidation (14%) Narang, PLoS One. 2014 Slide 19 Chronic Sinusitis Oral antibiotic therapy Scadding, CEA 2007 Protracted Bacterial Bronchitis (PBB) Oral antibiotic therapy + Chest physiotherapy Priftis, Chest 2013 Kompare, J Pediatr 2012 CHRONIC COUGH Slide 20 Slide 21 Infezioni Novit nella Terapia delle Malattie Respiratorie Slide 22 1.Clinicians should not administer salbutamol 2.Clinicians should not administer epinephrine 3.Nebulized hypertonic saline should not be administered in the ED 4.Clinicians may administer nebulized hyper. saline (3%) in hospital 5.Clinicians should not administer systemic steroids in any setting 6.Clinicians may choose not to administer O 2 if SaO 2 > 90% 7.Clinicians may choose not to use continuous pulse oximetry 8.Clinicians should not use chest physiotherapy 9.Clinicians should not administer antibacterial medications to infants and children unless there is a concomitant bacterial infection, or a strong suspicion of one 10.Clinicians should administer nasogastric or intravenous fluids for infants who cannot maintain hydration orally Pediatrics.Pediatrics. 2014 Nov Slide 23 Changes in gastric and lung microflora with acid suppression. Rosen, JAMA Pediatr. 2014 Oct 5yr prospective study of 99 pts 1-18 yrs (cough at least 3 times/wk for at least 1 month broncho/gastroscopy; 48% acid suppressed) p < 0.05 Gastric bacterial concentrations, log 10 CFU/ml Bacillus; Dermabacter; Lactobacillus; Peptostreptococcus; Capnocytophaga; Propionibacterium Positive correlations between proximal nonacid reflux & lung bacterial concentrations (r 0.5!) Lung Gastric flora can influence lung flora through nonacid GER in acid-suppressed patients Acid suppression may need to be limited in patients at risk for infections Slide 24 Oral Amoxicillin: 1 choice: effective, tolerated, cheap Alternatives: co-amoxiclav, cefaclor, macrolides Macrolides: -add if no response to 1 st line therapy after 48 h (see severity assessment) -use if Mycoplasma/Chlamydia is suspected Pediatric CAP: which antibiotic should be used? Thorax 2011, CID 2011 Slide 25 Parenteral therapy Preferred: intravenous azithromycin (10 mg/kg on days 1 and 2 of therapy; transition to oral therapy if possible) Alternatives: intravenous erythromycin lactobionate (20 mg/kg/d every 6 hours) Oral therapy (step-down therapy or mild infection) Preferred: azithromycin (10 mg/kg on day 1, followed by 5 mg/kg/d once daily on days 25) Alternatives: clarithromycin (15 mg/kg/d in 2 doses) or oral erythromycin (40 mg/kg/d in 4 doses); INPATIENTS Management of Atypical Bacteria Macrolides at least x 14 days (azithro 5 days) OUTPATIENTS CID 2011 Slide 26 Erythromycin interacts with motilin receptors, induces strong gastric and pyloric bulb contractions infantile hypertrophic pyloric stenosis (3 to 12 wks old infants: 1-2 % o births) 5 giorni di terapia per un bambino di 15 Kg: claritromicina ~ 16 azitromicina ~ 22 eritromicina ~ 10 PEARLS Slide 27 Use of macrolides in mother and child and risk of infantile hypertrophic pyloric stenosis. Lund BMJ 2014. Erythromycin is associated with hypertrophic pyloric stenosis risk, but no certainty about other macrolides (pertussis !!!!!) Slide 28 A comparative clinical study of macrolide-sensitive and macrolide-resistant Mycoplasma p. in pediatric patients. Matsubara J Infect Chemother 2009. 68% macrolide -sensitive 32% macrolide -resistant Efficacy of macrolide therapy 91.5% for macrolide sensitive 22.7% for macrolide resistance (p < 0.01) In children increasing prevalence of macrolide-resistant M. pneumoniae More prolonged fever (> 48 hr) and cough Macrolide sensitive Macrolide resistent Fever days1.54.0 Cough days7.011.4 Slide 29 F requency of the A2063G mutation in 23S rRNA gene [significantly >> in children (61.3%) than adults (13.3%)] Yoo, Antimicrob Agents Chemother. 2012 The resistance 30 ch. with Mycoplasma (PCR + serology) 70% resistant (fever) After minocycline, fever disappeared (48 h) Antibiotic Management of Atypical Bacteria Mycoplasma (DNA copies) Kawai Respirology. 2012 Slide 30 Clinical Relevance of Mycoplasma macrolide resistance Cardinale, J Clin Microbiology 2013 Levofloxacin in macrolide resistant M. pneumoniae Slide 31 Oral therapy (step-down therapy or mild infection) INPATIENTS Management of Atypical Bacteria Preferred: intravenous azithromycin (10 mg/kg on days 1 and 2 of therapy; transition to oral therapy if possible) Alternatives: intravenous erythromycin lactobionate (20 mg/kg/d every 6 hours) or levofloxacin (16-20 mg/kg/d every 12 hours; maximum daily dose, 750 mg) OUTPATIENTS Parenteral therapy Prefer