Acute asthma in emergency departments in France A multicenter ...

Acute asthma in emergency departments in France A multicenter ...

Asthme Aigu Grave Prise en charge initiale Sergio Salmeron Service de Pneumologie Groupe Hospitalier Paris Saint Joseph Module Respiratoire - novembre 2018 DES Mdecine Intensive-Ranimation DESC Ranimation DES Pneumologie La mortalit lie lasthme est en dcroissance en France Plan asthme Taux standardiss de mortalit par asthme, tous ges, France mtropolitaine, 1990-1999 et 2000-2011 Invs 2013 Tual S, allergy 2008 Mortalit li lasthme en France Conditions associes Fuhrman C, J Asthma 2009 Mortalit li lasthme en France Conditions associes

Fuhrman C, J Asthma 2009 Mortalit prhospitalire tude ESPACE Enqute prise en charge de lasthme en prhospitalier par les SMUR. 1040 dossiers collects par 47 SMUR dpendants de 30 SAMU de janvier 2004 dcembre 2008. 868 dossiers inclus, 752 diagnostic certain (87%) Vs 80% dans ASUR1. 116 diagnostic vraisemblable (13%) VS 20% dans ASUR1. Orientation: Urgences: 620 (80%) Salle:11 (2%), Ranimation144 (18%) Dcs pendant le transport: 4 (0.5%) Claire Broche SFAR 2010 PEC prhospitalire tude ESPACE Svre Modr Intermittent 53%

Lger Claire Broche SFAR 2010 Signes de gravit - AAG Signes dalarme Signes de gravit Troubles de vigilance Orthopne Contraction SC Sueurs Parole impossible Agitation Pauses respiratoires Silence auscultatoire Cyanose Attention discordance Clinique DEP (jeunes) 150 l/min FC 110 / min FR 30 / min DEP < 30 % th PaCO2 > 40

mm Hg Radio seulement si AAG ou admission Courtoisie Pr M. Brauner Facteurs prdisposant l AAG Facteurs socio dmographiques - Conditions socio-conomiques dfavorises, prcarit. - Difficults d'accs aux soins peu de contact avec MT Facteurs socio psychologiques - Non compliance au traitement ou aux rendez-vous - Dni de la maladie, poursuite du tabagisme, corticophobie - Maladie psychiatrique ou pb psychologiques graves - alcoolisme Lack of a written asthma action plan GINA 2016 Facteurs prdisposant l AAG Histoire de l'asthme Intubation

prcdente pour AAG Hospit/consult rptes aux urgences l'anne prcdente Hospitalisation ou consultation urgences mois prcdent Pneumothorax ou pneumomdiastin au cours d'un AAG Maladie cardiaque ou respiratoire svre associe Corticothrapie Intolrance orale au long cours laspirine et aux AINS +++, - Sensibilisation Alternaria,

Emoussement de la sensation de dyspne Identify patients at risk of asthma-related death Not currently using ICS, or poor adherence with ICS Currently using or recently stopped using OCS (indicating the severity of recent events) Over-use of SABAs, especially if more than 1 canister/month Lack of a written asthma action plan Flag these patients for more frequent review Importance en consultation danesthsie GINA 2017, Box 4-1 Exacerbations de lasthme en France 2004 ASUR2 Application critres dhospitalisation

Enqute multicentrique prospective n = 3153 Traitement standardis, Critres dadmission prdfinis Gravit larrive Asthme aigu grave 17% 73% Exacerbation svre 56% Exacerba lgre/modre27% Mesure du DEP 91% Admissions 33% Cortic Inhals sortie 66% Cortic Oraux sortie 54% AAG Rapidit dvolution de la crise Crise progressive > 6 h souvent jours 80 - 90% cas Femmes ++

Infections resp ++ Gravit arrive Rponse lente au TT Inflammation ++ osinos Asthme suraigu < 3 h ou 6 h 10 20% cas Hommes ++ Allergnes, Aspirine Stress, exercice Gravit ++ Rponse rapide au TT Bronchospasme ++ neutros Wasserfallen AJRCCM 1994, OHollaren NEJM 1991, Picado ERJ 1999, Bock JACI 2001 Relation obstruction bronchique et PaCO2 Une PaCO2 > 40 mmHg Tmoigne dune obstruction Majeure VEMS < 25% pred Mais AAG hypocapnique possible !!! Mac Fadden, N Engl J Med, 1968

AAG Ventilation 16 16 14 14 12 12 10 10 8 VE 8 6 VA 6

4 4 2 2 0 0 VA L/min VA L/min Point dinflexion de la ventilation en cas dobstruction svre 0 10 20 30 40 50 60 70 80 90 100 Pred-FEV1 % Mc Fadden, NEJM 1968 Traitement de lAA aux Urgences Traitement conventionnel Premire ligne : 2+inhals (A), Antichol (B), corticodes (A),

Deuxime ligne : idem + 2+ IV, adr Traitement non conventionnel Sulfate de Magnsium Heliox https://ginasthma.org/2018 Ketamine https://www.brit-thoracic.org.uk Reco SRLF-SFMU 2018 Halogns 2 Agonistes - Voies d'administration Rapidit daction et relation dose - effet des voies inhale et sous-cutane Change in FEV (%) 80 Sous cutane Orale Inhale 60 1.5 mg 40 0.375 mg

20 0.5 mg 0.25 mg 0 0 60 120 180 Time (min) 240 300 Dulfano, Glass 1976 AAG 2 agonistes nbuliss vs IV Supriorit de la voie inhale dans lAAG hypercapnique PEF 200 Pa CO2

Clinical Index ** 15 150 100 * 10 mm Hg L/min 50 * 5 40 50 0 0

1 hr 1 hr salbutamol N = 47 ** ** NEB Group IV Group Salmeron, AJRCCM 1994 NEB : 5mg x 2 IV : 0.5mg en 1h 0 *p 0.05 **p 0.001 1 hr AAG Corticodes systmiques Dlai daction similaire de 3 4 heures pour les voies orale et IV

% of pretreatment PEFR 180 Prednisolone orale Placebo oral Hydrocortisone I.V. Placebo I.V. saline 160 140 120 100 0 2 4 6 Hours 8 10

12 Ellul Micaleff 1975 Corticosteroids in the ED 140 120 % FEV 1 100 * Steroids Placebo * * Different from placebo 80

* 60 40 20 GINA 2016 0 -20 -5 0 5 10 15 Time (hours) Fanta, Am J Med 1983 20 25 Systemic GC speed the resolution

and should be used in all ASA Anticholinergiques - AAG Bnfice de lassociation aux 2 agonistes dans les formes les plus graves 100 FEV1 30% 90 90 80 80 FEV1 (% PREDICTED) FEV1 (% PREDICTED) 100 70 60 50 40 30 70 60

50 40 30 20 20 10 10 Pre 30 60 90 120 150 180 TIME ( min) IB bromure dipratropium C contrle FEV1 > 30% C n = 70 IB n = 58 Pre 30

60 90 120 150 180 TIME ( min) Rodrigo, AJRCCM 2000 AAG - Evolution des paramtres cliniques sous traitement Disparition de la dyspne aprs une amlioration modeste de lobstruction 400 3.5 Liters 3.0 MEFR FEV MMF 350 300 2.5 250

2.0 200 1.5 150 1.0 100 0.5 50 Liters/min 4.0 0 0 Base Donnes cliniques Disparition Best

Dyspne Disparition Disparition sibillants McFadden, Contraction SCM NEJM 1993 Rponse aux 2 agonistes aux urgences Rpartition en fonction critre de rponse prdfini DEP > 50 % 80 80 70 70 60 60 PEFR (% of Predicted) PEFR (% of Predicted) Non admis n = 81

50 40 30 20 40 30 20 10 0 0 Salbutamol (mg) n = 35 50 10 0.0 1.2 2.4 3.6 4.8 6.0 7.2 Admis 1 heure 0.0 1.2 2.4 3.6 4.8 6.0 7.2 Salbutamol (mg)

Rodrigo, Chest 1998 Sujet g- Gravit et rponse au traitement initial - Cohorte ASUR-1 DEP initial, % th 2 nbuliss Antichol nbuliss Corticodes syst ASUR, Lancet 2001 < 65 ans p 65 ans 47 % <0,0001 35 % 91 % ns 48 % ns 58 % ns

90 % 52 % 57 % ASUR 2 - Rechutes un mois non lies la gravit larrive Catgorie de gravit Groupe A Groupe B N = 260 N = 261 P value Rechutes 1 mois 38% 39% < 0.007 Asthme aigu grave, 32% 35%

0.7081 Exacerbation svre, 37% 41% 0.3622 Exacerbation lgre/mod, 42% 37% 0.2639 IV Magnsium AAG N = 248 Patients 18-60 yr FEV1 < 30% pred Placebo Magnesium n = 126 n = 122

Neb Salbutamol 2.5 mg/30 min IV Cortisone 100 mg IV Magnesium 2 g / 10-15 min or placebo Silverman, Chest 2002 GINA 2018 : Evidence A : DEP < 30% et/ou < 60% 1h post TT BTS 2016 : Evidence B : DEP < 50% et non rponse post TT AAG Traitements non conventionnels Ketamine 0,5 1 mg/kg en 2 4 min, suivi de 0,5 2 mg/kg/h Adrenaline 0,3 0,5 mg SC / IM si suspicion danaphylaxie Heliox Donnes anecdotiques, non recommand par BTS GINA Halogns - Sevoflurane AAG Patient 67 ans FD : Aspirine AAG ventil AC/FA rapide Sevoflurane Dispositif

AnaConDa Ruszkai Z, Can J Anesth 2014 Halogns - Sevoflurane AAG Patient 67 ans, AAG ventil, AC/FA rapide Sevoflurane, Dispositif AnaConDa Ruszkai Z, Can J Anesth 2014 Corticothrapie orale courte dure Prevention des rechutes aprs consultation aux urgences Probability of Remaining Reelapse-free (%) 100 48 47 45 46 43 90

45 42 40 39 44 38 80 43 42 40 37 35 39 38 34 32 70 31

30 27 60 26 25 50 0 0 2 4 6 8 10 12 14 16

18 20 Days after Emergency Room Treatment Chapmann, NEJM 1991 Observance Observance aprs aprs hospitalisation hospitalisation AAG AAG N = 60 hospitaliss AAG Intubation prcdente 33% Intubation actuelle 13% TT de sortie standardis PDN 40 mg/J pdt 7j FP 500 g x 2/j Technique de prise vrifie Instructions crites

Patients revus J14 Questionnaire Monitoring lectronique Krishnan, AJRCCM 2004 AAG Conclusions Traitement initial standardis 2 + nbuliss fortes doses, anticholinergiques Niveau A corticodes Traitement secondaire Sulfate de Mg IV Niveau A - B Autres traitements valuer Evaluation prcoce de la rponse au TT (1h) Prvention+++ Situations difficiles (perception obstruction, observance) Interrogatoire contrle screening pr-op Sortie : optimiser TT inhal, Lien Pneumologue Education thrapeutique

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