Điều trị cắt cơn hen phế quản trẻ em BS Nguyễn Minh Tiến BV Nhi Đồng 1 Update: 18.3.2017

1. ĐIỀU TRỊ CẮT CƠN HEN PHẾ
QUẢN Ở TRẺ EM
BSCK2. NGUYỄN MINH TIẾN
BỆNH VIỆN NHI ĐỒNG 1

2. Ñònh nghóa hen phế quản (HPQ)
 Vieâm maïn tính ñöôøng thôû (Thaâm nhieãm TB
vieâm: mast cell, eosinophile vaø lymphocyte.)
 Côn HPQ:
 co thaét, phuø neà, taêng tieát.
 khoø kheø, ho, khoù thôû.
 töï khoûi hoaëc do ñieàu trò.
 taùi phaùt .

3. Caùc yeáu toá nguy cô
(phaùt trieån thaønh beänh suyeãn)
Taêng ñaùp öùng
ñöôøng thôû
Giôùi haïn
ñöôøng thôû
TRIEÄU CHÖÙNG
Caùc yeáu toá nguy cô
(khôûi phaùt côn suyeãn)
HPQ: Vieâm maïn tính ñöôøng thôû.

4. Hình aûnh Giaûi phaãu beänh lyù
TIEÁN TRÌNH VIEÂM TRONG SUYEÃN
Taêng saûn
tuyeán nhaøy
Bong vaõy
TB bieåu moâ
Nuùt nhaøy
Daøy
maøng
ñaùy
Phuø
Phì ñaïi vaø co thaét cô trôn Thaâm nhieãm TB vieâm

5. ÑIEÀU TRÒ CAÉT CÔN
GINA 2016, Nelson 2016
NHLBI 2007

11. ÑIEÀU TRÒ BAN ĐẦU

12. GINA
2014

13. GINA
2016

15. NHLBI
2007

16. Current evidence supports the use of CBA in patients with severe
acute asthma who present to the emergency department to
increase their pulmonary functions and reduce hospitalisation.
Moreover, CBA treatment appears to be safe and well tolerated in
patients who receive it.
2011

17. Khí dung liên tục

18. Ñieàu trò côn nheï & trung bình
Ñieàu trò ban ñaàu:
 2 giao caûm: moãi 20 phuùt x 3
bình hít ñònh lieàu MDI + spacer
hoaëc khí dung
 Oxygen ñeå ñaït SaO2 92- 95%
 Prednisone uoáng hoặc budesonide KD neáu
khoâng ñaùp öùng vôùi lieàu ñaàu tieân cuûa 2
giao caûm, hoặc đã dùng corticoid trước đây
TAÏI BEÄNH VIEÄN

29. Early USE OF INHALED
CORTICOSTEROIDS IN THE
EMERGENCY
DEPARTMENT TREATMENT OF
ACUTE ASTHMA

30. Main results
 Ten trials were selected for inclusion.
In the included trials, (5 adult, 5
paediatric), a total of 587 patients were
studied (294 ICS, 293 non-ICS treated).
Patients treated with ICS were less
likely to be admitted to hospital (OR:
0.32; 95% CI: 0.18, 0.54).
 This benefit was evident in the
subgroup of patients not receiving
concomitant systemic steroids (CS) (OR
0.27; 95% CI: 0.14, 0.52).

31. Main results
 Patients receiving concomitant CS
showed a similar, but non-significant, trend
towards reduced admissions compared to
placebo treatment (OR 0.45; 95%CI: 0.2,
1.1).

32. Main results
 Patients receiving ICS also demonstrated
small, significant improvements in peak
expiratory flows (PEFR WMD: 7%; 95%CI:
4, 11%) and forced expiratory volumes
(FEV1 WMD: 6%; 95%CI: 2, 10%).
 A secondary analysis compared ICS alone
vs CS alone; in the seven trials included,
there was significant heterogeneity
between the study results for admission
rates

33. Authors’ conclusions
 Inhaled steroids reduced admission
rates in patients with acute asthma,
but it is unclear if there is a benefit of
ICS when used in addition to systemic
corticosteroids.

34. Publication status and date: New search for studies and content
updated (conclusions changed), published in Issue 12, 2012.
Review content assessed as up-to-date: 28 September 2012.

35. Main results
 Twenty trials were selected for inclusion in the primary
analysis (13 paediatric, seven adult), with a total number
of 1403 patients.
 Patients treated with ICS were less likely to be admitted
to hospital (OR 0.44; 95% CI 0.31 to 0.62; 12 studies; 960
patients)
 Subgroup analysis of hospital admissions based on
concomitant systemic corticosteroid use revealed
that both subgroups indicated benefit from ICS in reducing
hospital admissions (ICS and systemic corticosteroid
versus systemic corticosteroid: OR 0.54; 95% CI 0.36 to
0.81; 5 studies; N = 433; ICS versus placebo: OR 0.27;
95% CI 0.14 to 0.52; 7 studies; N= 527)

36. Admission to hospital

37.  Patients receiving ICS demonstrated
small, significant improvements in peak
expiratory flow (PEF: MD 7%; 95% CI 3%
to 11%) and forced expiratory volume in
one second (FEV1: MD 6%; 95% CI 2% to
10%) at three to four hours post
treatment)

38. Authors’ conclusions
 ICS therapy reduces hospital admissions in
patients with acute asthma who are not treated
with oral or intravenous corticosteroids.
 They may also reduce admissions when they are
used in addition to systemic corticosteroids

39. Volovitz 1998 (Comparison to systemic
steroids: single dose administration)
Asthma symptom scores improved more quickly with budesonide than with
prednisolone during the first week after discharge, and budesonide treatment
was not associated with the cortisol suppression seen at Week 3 in children who
had received prednisolone

40. Milani 2004 (Comparison to systemic
steroids: single dose administration)
A combination of single-dose nebulized budesonide + salbutamol
# oral prednisone + salbutamol to improve symptom severity,
but the latter increases hemoglobin saturation in mild &
moderate exacerbation of asthma

41. Devidayal 1999 (Comparison to systemic
steroids: repeated dosing)
SpO2, RR, pulmonary index and respiratory distress score were
significantly improved in the budesonide group compared to
prednisolone group (p < 0.01). The proportion of patients who
were fit for discharge at the end of 2 h after the third dose of
nebulization was significantly higher in the budesonide group than
in the prednisolone group (22/ 41, 54% vs 7/39, 18%, p < 0.001)

42. Differences between ICS
in the acute setting
 Budesonide is readily dissolved in human
bronchial secretions and is rapidly
absorbed irrespective of the site of
deposition, which contrasts with the
dissolution profile of more lipophilic
compounds, such as fluticasone
Högger P., Rawert I., Rohdewald P.: Dissolution, tissue binding and
kinetics of receptor binding of inhaled glucocorticoids. Eur Respir
J 6. (Suppl 17): 584.1993

43. KHÍ DUNG BUDESONIDE
 Budesonide 0,5-1mg x 2-4/ngày
 Budesonide khí dung: thay thế corticoid
uống khi bệnh nhân có 1 trong các biểu
hiện sau:
. Loét dạ dày tá tràng,
. XHTH,
. Thủy đậu đang tiến triển,
. Tiểu đường, cao huyết áp hoặc
. Bất dung nạp corticoid uống
. Tác dụng phụ corticoid đường uống

44. LIỀU LƯỢNG TRONG CẮT
CƠN HEN Ở TRẺ EM
 Budesonide: hiệu quả, an toàn
500-1000 mcg / lần x 2-4 lần / ngày

45. BỆNH ÁN MINH HỌA
•BN: Ng. M. T, nam, 3 tuổi, CN 14kg
ĐC: Q11-TPHCM
NV: Ngày 6/5/2013
LDNV: thở mệt
•BS:
N1-2: em ho, khò khè, không sốt, nôn ói  thở
mệt,  NV
TC: VTPQ lúc 6 tháng tuổi.

46. TTLNV
Tỉnh, đừ
Môi hồng/ KT, SpO2 93%
Chi ấm, CRT < 2s, Mạch quay rõ 140 l/ph
T0 37,50C
Thở đều co lõm ngực 44 l/ph
Tim đều, phổi ran ngáy, rít
Bụng mềm, gan không to.
Cổ mềm
 Suyễn cơn trung bình, bậc 1, chưa kiểm
soát

47. XỬ TRÍ
 KD ventolin 2,5mg/2,5ml
 Pulmicort 0,5mg/2ml 2 ống
Sau 20 ph, tình trạng em tỉnh, thở 40
lần/ph, RLN nhẹ, phổi ran ngáy, bớt ran
rít
KD ventolin 2,5mg/2,5ml sau đó mỗi 6 giờ
KD pulmicort 0,5mg mỗi 12 giờ

48. A direct comparison between nebulized budesonide
(Pulmicort® Respules®), has been used in many
studies of inhaled steroids in acute asthma, and oral
prednisolone shows a clear benefit for the former
Wilson: compared the systemic activity of budesonide
1, 2 and 4 mg with oral prednisolone 5, 10, and 20 mg
over 4 days in patients with mild asthma. For morning
plasma cortisol, serum osteocalcin, and blood
eosinophils, there was a significant dose-related
suppression with prednisolone but not with
budesonide
Wilson A.M., McFarlane L.C., Lipworth B.J.: Systemic bioactivity profiles of oral prednisolone and
nebulized budesonide in adult asthmatics. Chest 114. 1022-1027.1998

49. Significant dose-
related suppression
with prednisolone
for
.plasma cortisol
for blood
.eosinophils and
.osteocalcin, but no
significant dose-
response effect
with budesonide

50. Individual values for 8am plasma cortisol with each treatment. The
interrupted line represents the lower limit of the normal reference range
at <150 nmol/L

51.  Dolan: investigated the adrenal dynamics in
asthmatic children 11–15 years old who
during the previous year had received
repeated “bursts” (less than 7 days) of short-
term high-dose prednisone (1–2 mg/kg/day)
for acute exacerbations. Most children had a
normal adrenal response, however in those
who received more than 4 “bursts” per year a
subnormal response was seen.
Dolan L.M., Kesarwala H.H., Holroyde J.C., Fischer T.J.: Short-term, high-dose, systemic
steroids in children with asthma: the effect on the hypothalamic–pituitary–adrenal axis. J
Allergy Clin Immunol 80. 81-87.1987

52. Reccommendation from NHLBI/Expert Panel Report 3:
Use of ICS for Management of Acute Asthma 2007
 Home treatment: Doubling the ICS dose is not sufficiently
(Evidence B) effective at reducing the severity or
preventing progression of exacerbations. However, higher
doses (quadrupling the dose) of an ICS may be effective in
management of acute asthma exacerbations.
 For patients who experience substantial adverse effects
with oral systemic corticosteroids (e.g., mood changes,
worsening diabetes), high-dose ICS may be an effective
alternative for mild to moderate exacerbations

53. Reccommendation from GINA 2012: Use
of ICS for Management of Acute Asthma

54. High doses of budesonide
 In the systematic review by Edmonds
. the high doses of budesonide 2400 μg via
nebulizer as three doses of 800 μg at 30-
min intervals
. budesonide 2000 μg via nebulizer every 8
h
. budesonide 1600 μg via DPI
. budesonide via MDI with spacer as three
400 μg doses at 30-min intervals

55. Differences between ICS in the acute setting
 Budesonide is readily dissolved in
human bronchial secretions and is
rapidly absorbed irrespective of the
site of deposition, which contrasts
with the dissolution profile of more
lipophilic compounds, such as
fluticasone

57. Ñieàu trò côn suyeãn naëng
Ñieàu trò ban ñaàu:
° Oxy giöõ SaO2 92 - 95%.
° KD 2 giao caûm + KD Ipratropium
moãi 20 phuùt x 3 laàn,
° Hydrocortisone: 5mg/kg/laàn TM
/ methylprednisolone 1mg/kg/lần
° Terbutaline/adrenaline TDD: cơn nguy kịch
TAÏI BEÄNH VIEÄN

58. ÑIEÀU TRÒ TIẾP THEO

59. GINA
2014

60. GINA
2016

61. NHLBI
2007

62. Ñieàu trò côn nheï & trung bình
Ñieàu trò tieáp theo:
 Ñaùp öùng toát: ñieàu trò ngoaïi truù:
– Tieáp tuïc MDI hoaëc uoáng 2 giao caûm moãi 4-6 giôø  1-2
ngaøy
– Corticoids uoáng/budesonide KD
 Ñaùp öùng khoâng hoaøn toaøn hoặc không đáp ứng:
- KD 2 mỗi giờ x 3 giờ
- Corticoid uống/budesonide KD
- KD 2 + Ipratropium (cơn TB) mỗi giờ x 3 giờ
 Diễn tiến xấu hơn (cơn nặng): xöû trí nhö côn naëng
TAÏI BEÄNH VIEÄN

63. Ñieàu trò côn HPQ naëng
Điều trị tiếp theo (G2)
Nếu đáp ứng tốt:
° Oxy giöõ SaO2 92-95%.
° Tieáp tuïc khí dung :
2 giao caûm moãi 2-4giôø
Anti-cholinnergic moãi 4-6giôø
° Cort. TM
TAÏI BEÄNH VIEÄN

64. Ñieàu trò côn HPQ naëng
Ñieàu trò tieáp theo (G2):
Không đáp ứng
° Oxy giöõ SaO2 92-95%.
° Tieáp tuïc khí dung moãi giôø/3 giờ:
2 giao caûm
Anti-cholinnergic
° Cort. TM + budesonide KD
° MgSO4 TTM x 1 liều, nếu ≥ 1 tuổi
° Aminophylline TTM nếu < 1 tuổi
TAÏI BEÄNH VIEÄN

65. GINA
2016

66. GINA 2016

67. GINA 2016

68. GINA 2016

69. The additive benefit of inhaled steroids when used
with systemic corticosteroids remains uncertain,
although the results of this systematic review
suggest an additive effect.

70. Sung 1998 (Inhaled budesonide in addition
to systemic steroids)
Sung L, Osmond MH, Klassen TP. Randomized, controlled trial of inhaled budesonide as an adjunct to oral
prednisone in acute asthma. Acad Emerg Med 1998;5:209–13
.The PIS (Pulmonary Index Score) at 1 hour had a tendency to be lower in
the budesonide group (median = 5) as compared with the placebo group
(median = 6; p = 0.07).
.These preliminary results suggest that nebulized budesonide may be an
effective adjunct to oral prednisone in the management of moderate to
severe asthma exacerbations

71. Ñieàu trò côn HPQ naëng
Sau 2 giờ (G3):
Nếu không đáp ứng:
° Oxy giöõ SaO2 92-95%.
° Tieáp tuïc khí dung :
2 giao caûm moãi 1-4giôø
Anti-cholinnergic moãi 4-6giôø
° Cort. TM + budesonide khí dung
° 2 giao caûm TTM/Aminophylline TTM
TAÏI BEÄNH VIEÄN

72. Aminophylline (5-7 mg/kg intravenous loading dose, followed by
infusion of 0.5 to 1 mg/kg per hour that is titrated based upon
levels).
 •6 weeks to 6 months – 0.5 mg/kg/hour
 •6 to 12 months – 0.6 to 0.7 mg/kg/hour
 •1 to 9 years – 1 mg/kg/hour
 •9 to 16 years – 0.8 mg/kg/hour
Aminophylline has a mean volume of distribution of 0.5 L/kg. Thus, a
loading dose of 6 mg/kg should generate a serum level of
approximately 12 microgram/mL. Therapeutic levels range between
10 and 20microgram/mL. We suggest target levels of 12 to
15 microgram/mL, particularly upon initiation of therapy. Steady-
state levels are checked 6 to 12 hours following the bolus/initiation of
the infusion. If the patient's respiratory status does not improve and
the six-hour theophylline level is below 15 microgram/mL, then the
infusion is increased proportionately to a target level of
15 microgram/mL. Serum levels of aminophylline should be
measured once daily (after desired level or response to therapy
achieved) and as needed when toxicity is suspected (severe
tachycardia, anxiety, persistent emesis, dysrhythmias, and seizures)

73. DOAÏ NGÖNG THÔÛ
DAÁU HIEÄU NAËNG DOÏA NGÖNG THÔÛ
O2 + 2 TDD
+ 2 KD+
Anticholinergic KD
Cort. TM
CÔN NAËNG
O2 + 2 KD + Antic KD
Cort.TM
CÔN NHEÏ/
TBình
2 MDI/KD
+
_
+
_
XẤU
Xử trí như
suyễn nặng
TOÁT
2KD/MDI
Predni (u)
KHOÂNG ÑÖ/XAÁU
2 + Anticho. KD
Cort. TM
MgSO4/Amino (<1t)
 / H.TOAØN
2KD/giờ x 3
2KD+Ipra(TB)/giờ x 3
Predni (u)
KHOÂNG ÑÖ/XAÁU
+ 2 TTM /Aminop. TTM
TOÁT
2 MDI/(u)
4-6 giôø
G2
G3

74. BỆNH ÁN MINH HỌA
•BN: B. G. H, nam, 18 tháng tuổi, CN 11kg
ĐC: Q3-TPHCM
NV: Ngày 4/12/2012
LDNV: thở mệt
•BS:
N1-2: em ho, sổ mũi, khò khè, sốt nhẹ,
N3: khò khè, thở mệt,  NV
TC: thường có nhiều đợt khò khè, điều trị tư bớt.

75. TTLNV
Quấy khóc, bứt rứt
Môi tím/ KT, SpO2 86%
Chi ấm, CRT < 2s, Mạch quay rõ 152 l/ph
T0 380C
Thở đều co lõm ngực 56 l/ph
Tim đều, phổi ran ngáy, rít
Bụng mềm, gan không to.
Cổ mềm
 Suyễn cơn trung bình, bậc 1, chưa kiểm
soát

76. XỬ TRÍ
 KD ventolin + combivent/20ph x 3, Hydro. TM
Sau 1G, tình trạng em đừ, thở 52 lần/ph, RLN
(++), phổi ran ngáy, rít
KD ventolin + combivent /giờ x 3, MgSO4 TTM
Không đáp ứng: NT 172 lần/ph  Diaphyllin
TTM, Pulmicort 0,5mg/2ml 2 ống KD x 2

77. BÙI GIA H. 20 TH, HPQ NẶNG
: KD combivent, Pulmicort, hydrocortisone