6-Moeciu- sept. 2012 - Eficiența adrenalinei .pptx

7312019 6-Moeciu- sept 2012 - Eficiența adrenalinei pptx

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ȘCOALA DE VARĂA SOCIETĂȚII ROMAcircNE DE

PEDIATRIE Moeciu ndash septembrie - 2012



Cazul 5

bull copil icircn vacircrstă de 1 an

bull debut de 2 zile cu obstrucție nazală și rinoree

bull

de o zi respirația a devenit dificilă șizgomotoasă

bull ex obiectiv wheezing

bull

dg bronșiolită ac bull cu ocazia unor cazuri terapia cu Salbutamol nu

a influențat convingător wheezing-ul



Cazul 5

bull Care este eficiența epinefrinei (adrenalinei) icircnaerosoli menționată icircn literatura despecialitate



Probleme

bull APP - Wheezing disorders

bull Caracterul wheezingului

bull Gradul efortului respirator

bull Frecventa respiratorie - +- tahipnee

bull Istoric familialpers de atopie

bull Evaluarea răspunsului la salbutamol (dozemod de adm corespunzătoare)

bull +- RSV IgE





Academia Americană de Pediatrie AAP - Clinical Practice Guidelines

bull Bronhodilatatoarele nu vor fi utilizate derutină

bull O probă opțională cu αszlig agonist va fi

continuată doar dacă o evaluare obiectivăindică un răspuns clinic



CHEST Journal - Guideine

bull Bronșiolita icircn prezentarea ei tipică va fi

considerată ca o afecțiune autolimitatăcaracterizată de edem bronșiolar și nubronhospasm

bull Utilizarea de rutină a bronhodilatatoarelor icircnaerosoli nu este recomandată

bull

Aerosolii cu adrenalina racemică vor fi luați icircnconsiderare la anumiți pacienți dacă nu seobservă ameliorare clinică nu se va mai repetaadministrarea



Salbutamolul

Efecte terapeutice

bull β2 adrenergic

bull relaxează mm netedă bronșică scade rezistența icircn CA

bull suprimă eliberarea mediatorilor inflam din mastocite bull scade permeabilitatea microvasculară icircmbunătățește activitatea

mucociliară

Efecte secundare

bull tremorul prin stimularea directă a rec β2 din mușchiischeletici

bull tahicardia amp palpitațiile ndash mai rare icircn cazul agoniștilorselectivi



Lipsa de răspuns

bull desensibilizarea CA consecutivă administrăriirepetate de doze mari de salbutamol șisauinf cu RSV

bull musculatura netedă peribronșică redusă lasugar

bull penetrareadistribuția scăzută a β

adrenergicelor icircn arborele bronșic al sugaruluicu bronșiolită



Adrenalina

Efecte terapeutice

bull efect α ndash scade secreția bronșică și edemul mucoasei bull efect β ndash relaxează musculatura netedă bronșică reduce

eliberarea mediatorilor mastocitari ai inflamației

bull 01 mlkgdoză din 11000

bull pick effect la 30 min durata 2 ore

limite

bull Ameliorarea edemului căilor respiratorii nu este susținută

și nu influențează istoria naturală a bolii bull Procesul inflamator inițiat de RSV sau alte virusuri

respiratorii este neinfluențat hipersecreția și edemulbronșic reapar după epuizarea efectului terapeutic



BMC Pediatr 2005 5 7

Published online 2005 May 5 1011861471-2431-5-71 A meta-analysis

of randomized controlled trials evaluating the efficacy of

epinephrine for the treatment of acute viral

bronchiolitis(Hartling L Wiebe N Russell K Patel H Klassen TP)

OBJECTIVE

bull To systematically review randomized controlledtrials comparing inhaled or systemic epinephrine vs

placebo or other bronchodilators

DATA SOURCES

MEDLINE EMBASE the Cochrane Central Register of

Controlled Trials primary authors and reference lists

bull 14 studies included



CONCLUSIONSbull Epinephrine may be favorable compared with placebo

and albuterol for short-term benefits among

outpatients

bull among outpatients results favored epinephrinecompared with placebo for clinical score at 60 minutes

oxygen saturation at 30 minutes respiratory rate at 30

minutes

bull There is insufficient evidence to support the use of

epinephrine among inpatients

bull Large multicentered trials are required before routine

use among outpatients can be strongly recommended



Cochrane Database Syst Rev 2011 Jun

15(6)CD0031232 Epinephrine for

bronchiolitisHartling L Bialy LM Vandermeer B Tjosvold L Johnson

DW Plint AC Klassen TP Patel H Fernandes RM

bull 19 studies included (2256 participants)

bull randomized controlled trials comparing

epinephrine to placebo or another

intervention involving children less than two

years with acute viral bronchiolitis



SEARCH STRATEGY

bull searched CENTRAL (2010 Issue 3) which contains the

Acute Respiratory Infections Groups Specialized Register MEDLINE (1950 to September Week 2 2010)

EMBASE (1980 to September 2010) Scopus (1823 to

September 2010) PubMed (March 2010) LILACS (1985

to September 2010) and Iran MedEx (1998 toSeptember 2010)


BACKGROUND

bull Bronchodilators are commonly used for acute

bronchiolitis despite uncertain effectiveness

OBJECTIVES

bull To examine the efficacy and safety of epinephrine in



Main results

bull

Epinephrine versus placebo among outpatients showed asignificant reduction in admissions at Day 1 (risk ratio (RR)

067 95 confidence interval (CI) 050 to 089)

bull There was no difference in LOS for inpatients

bullEpinephrine versus salbutamol showed no differencesamong outpatients for admissions at Day 1 or 7

Authorsrsquo conclusions

bull This review demonstrates the superiority of epinephrine

compared to placebo for short-term outcomes for outpatients particularly in the first 24 hours of care

Hartling L Wiebe N Russell K Patel H Klassen TP 3 A meta



Hartling L Wiebe N Russell K Patel H Klassen TP 3 A meta-

analysis of randomized controlled trials evaluating the

efficacy of epinephrine for the treatment of acute viral

bronchiolitis

( Arch Pediatr Adolesc Med 2003 157957 ndash 964)bull bull 14 clinical trials (7 inpatient 6 outpatient and 1 unknown) were

included in this meta-analysis

POPULATION STUDIED bull the researchers included randomized double-blind clinical trials

evaluating the efficacy of epinephrine vs placebo or epinephrine vs

other bronchodilators in the treatment of bronchiolitis for

hospitalized or ambulatory patients aged 2 years or younger

OUTCOMES MEASURED

bull Clinical scores of response at different times after treatment changes in

oxygen saturation ldquoimprovementrdquo length of stay and pallor after

treatment

bull



Results

bull Compared with placebo in the out-patient studies

epinephrine produced modest improvement in clinical

scores 60 minutes after treatment Oxygenation

modestly improved after 30 minutesbull When comparing epinephrine with albuterol no

differences were seen in any measured outcomes in

inpatients

bull However some outcomes were different amongoutpatients Changes in oxygenation after 60 minutes

ldquoimprovementrdquo and pallor were statistically better

with epinephrine compared with albuterol



Limite

bull the small size of the studies included in this

meta-analysis (the largest including only 194

patients)

bull the absence of a reliable clinical scoring

system to measure response in bronchiolitis

(trials used 6 different clinical scores)



King VJ Viswanathan M Bordley WC et al

4 Pharmacologic treatment of bronchiolitis in infants and

children a systematic review Arch Pediatr Adolesc Med

2004158127 ndash37

METHODS

Data sources

bull

Medline (January 1980 to November 2002) CochraneCentral Register of Controlled Trials reference lists

and technical experts

Outcomes

bull death short and long term morbidity and use of health services

Main results

bull

44 RCTs of commonly used interventions met theselection criteria



Main results

Nebulised epinephrine

(8 RCTs 660 children)

bull better than salbutamol for reducing hospital admission

bull better clinical scores immediately after epinephrine treatment

than after control treatment

bull the difference did not persist at 24 and 36 hours

β2 agonist

bronchodilators(13 RCTs 956 children)

bull no benefit in admission rates or duration of hospital stay

bull 3 of 12 RCTs showed short term improvement in clinical scores

30 ndash60 minutes after nebulised bronchodilator therapybull 1 RCT showed worse scores



Concluzii adrenalină vs salbutamol

Adrenalina icircn aerosoli

bull utilă la camera de gardă

bull efect benefic pe termen scurt

bull sunt necesare administrări repetate

Salbutamolul icircn aerosoli

bull util la copiii cu teren atopic wheezing recurent

Se icircntrerupe administrarea dacă nu se observă ameliorare



Direcții de cercetare

bull bronșiolita fiind un dg icircn principal clinic se

impune găsirea unui (effective diagnostic tools)

instrument diagnostic eficient pt managementul

bolii

bull urmărirea unor rezultate relevante clinic care săconteze pt părinți clinicieni și pt sistemul desănătate

bull evaluarea influenței tratamentelor (cu efectterapeutic pe termen scurt dovedit) asupra

calității vieții copilului cu bronșiolită



Cazul 5

bull copil icircn vacircrstă de 1 an

bull debut de 2 zile cu obstrucție nazală și rinoree

bull

de o zi respirația a devenit dificilă șizgomotoasă

bull ex obiectiv wheezing

bull

dg bronșiolită ac bull cu ocazia unor cazuri terapia cu Salbutamol nu

a influențat convingător wheezing-ul



Cazul 5




Probleme







bull +- RSV IgE















bull




Salbutamolul

Efecte terapeutice

bull β2 adrenergic



mucociliară

Efecte secundare





Lipsa de răspuns







Adrenalina

Efecte terapeutice





limite











OBJECTIVE



DATA SOURCES








outpatients



minutes


















SEARCH STRATEGY







BACKGROUND



OBJECTIVES




Main results

bull














bronchiolitis







OUTCOMES MEASURED



treatment

bull



Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii






Cazul 5




Probleme







bull +- RSV IgE















bull




Salbutamolul

Efecte terapeutice

bull β2 adrenergic



mucociliară

Efecte secundare





Lipsa de răspuns







Adrenalina

Efecte terapeutice





limite











OBJECTIVE



DATA SOURCES








outpatients



minutes


















SEARCH STRATEGY







BACKGROUND



OBJECTIVES




Main results

bull














bronchiolitis







OUTCOMES MEASURED



treatment

bull



Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii






Probleme







bull +- RSV IgE















bull




Salbutamolul

Efecte terapeutice

bull β2 adrenergic



mucociliară

Efecte secundare





Lipsa de răspuns







Adrenalina

Efecte terapeutice





limite











OBJECTIVE



DATA SOURCES








outpatients



minutes


















SEARCH STRATEGY







BACKGROUND



OBJECTIVES




Main results

bull














bronchiolitis







OUTCOMES MEASURED



treatment

bull



Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii


















bull




Salbutamolul

Efecte terapeutice

bull β2 adrenergic



mucociliară

Efecte secundare





Lipsa de răspuns







Adrenalina

Efecte terapeutice





limite











OBJECTIVE



DATA SOURCES








outpatients



minutes


















SEARCH STRATEGY







BACKGROUND



OBJECTIVES




Main results

bull














bronchiolitis







OUTCOMES MEASURED



treatment

bull



Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii






Salbutamolul

Efecte terapeutice

bull β2 adrenergic



mucociliară

Efecte secundare





Lipsa de răspuns







Adrenalina

Efecte terapeutice





limite











OBJECTIVE



DATA SOURCES








outpatients



minutes


















SEARCH STRATEGY







BACKGROUND



OBJECTIVES




Main results

bull














bronchiolitis







OUTCOMES MEASURED



treatment

bull



Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii






Lipsa de răspuns







Adrenalina

Efecte terapeutice





limite











OBJECTIVE



DATA SOURCES








outpatients



minutes


















SEARCH STRATEGY







BACKGROUND



OBJECTIVES




Main results

bull














bronchiolitis







OUTCOMES MEASURED



treatment

bull



Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii






Adrenalina

Efecte terapeutice





limite











OBJECTIVE



DATA SOURCES








outpatients



minutes


















SEARCH STRATEGY







BACKGROUND



OBJECTIVES




Main results

bull














bronchiolitis







OUTCOMES MEASURED



treatment

bull



Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii











OBJECTIVE



DATA SOURCES








outpatients



minutes


















SEARCH STRATEGY







BACKGROUND



OBJECTIVES




Main results

bull














bronchiolitis







OUTCOMES MEASURED



treatment

bull



Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii








outpatients



minutes


















SEARCH STRATEGY







BACKGROUND



OBJECTIVES




Main results

bull














bronchiolitis







OUTCOMES MEASURED



treatment

bull



Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii

















SEARCH STRATEGY







BACKGROUND



OBJECTIVES




Main results

bull














bronchiolitis







OUTCOMES MEASURED



treatment

bull



Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii






Main results

bull














bronchiolitis







OUTCOMES MEASURED



treatment

bull



Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii









bronchiolitis







OUTCOMES MEASURED



treatment

bull



Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii






Results






inpatients






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii






Limite



patients)









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii









2004158127 ndash37

METHODS

Data sources

bull



Outcomes


Main results

bull




Main results







β2 agonist





















bolii






Main results







β2 agonist





















bolii




















bolii




6-Moeciu- sept. 2012 - Eficiența adrenalinei .pptx

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Transcript of 6-Moeciu- sept. 2012 - Eficiența adrenalinei .pptx