exacerbations aigues lors de bronchiectasies · « the panel unanimously agreed the definition as:...
TRANSCRIPT
![Page 1: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/1.jpg)
Exacerbations aigues lors de bronchiectasies
Prof. Jean-Paul Janssens Service de Pneumologie
Hôpital Cantonal Universitaire, Genève, Suisse
![Page 2: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/2.jpg)
René-Théophile-Marie-Hyacinthe Laennec; 1781-1826
![Page 3: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/3.jpg)
Prévalence
![Page 4: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/4.jpg)
1. S’assurer que le bilan étiologique a été fait ou le prévoir
![Page 5: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/5.jpg)
V Espinosa & al, RMS 2013
![Page 6: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/6.jpg)
MC Pasteur et al, AJRCCM, 2000
![Page 7: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/7.jpg)
Bilan étiologique minimal suggéré par l’ERS (2017)
• FSC • IgA, IgG, IgM • Recherche d’ABPA • Bacteriologie courante et mycobactéries
Mêmes recommandations pour la BTS
![Page 8: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/8.jpg)
V Espinosa & al, RMS 2013
(+ VIH)
![Page 9: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/9.jpg)
2. Définition d’une exacerbation
![Page 10: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/10.jpg)
« The panel unanimously agreed the definition as: “a person with bronchiectasis
with a deterioration in three or more of the following key symptoms for at least 48
hours: 1) cough, 2) sputum volume and/or consistency, 3) sputum purulence, 4)
breathlessness and/or exercise tolerance, 5) fatigue and/or malaise, 6)
haemoptysis, AND a clinician determines that a change in bronchiectasis treatment
is required”
1st World Bronchiectasis Conference in Hannover, July 2016
![Page 11: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/11.jpg)
Indication au traitement des exacerbations
S Finch et al; Eur Respir Monograph 2017
Pas d’éléments biologiques: CRP, FSC, proCT etc…. !
![Page 12: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/12.jpg)
E Poverino et al; ERJ, 2017
![Page 13: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/13.jpg)
Bactériologie: germes les plus couramment identifiés
• Haemophilus influenzae (ad 35% des patients)
• Moraxella Catarrhalis
• Streptococcus pneumoniae
• Staphylococcus aureus (rechercher CF, ABPA)
• Enterobacteriacae
• Pseudomonas aeruginosa (associé à des exacerbations plus fréquentes et un déclin fonctionnel plus rapide)
• Rares: Stenotrophomonas maltophilia, Achromobacter xylosoxidans
• Rôle des virus?
S Finch et al; Eur Respir Monograph 2017 MJ Harrison et al, ibid
BTS Guidelines, Thorax 2010
![Page 14: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/14.jpg)
JD Chalmers et al; COPD, 2017
![Page 15: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/15.jpg)
JD Chalmers et al; COPD, 2017
![Page 16: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/16.jpg)
3. Durée du traitement: consensus?
![Page 17: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/17.jpg)
Eva Polverino et al, ERJ 2017
![Page 18: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/18.jpg)
4. Modalités du traitement
![Page 19: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/19.jpg)
Traitement des exacerbations
• Autant que possible basée sur la bactériologie et les antibiogrammes
• Etre colonisé par un Pseudomonas ne veut pas dire que c’est le pathogène
responsable lors de chaque exacerbation (co-infections fréquentes)
![Page 20: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/20.jpg)
Traitement des exacerbations: choix des antibiotiques
• Si Haemophilus influenzae: amoxicilline 3 x 1 gr, ou moxifloxacine 400 mg 14
jours
• Traitements combinés non recommandés lors d’infection documentée par
Haemophilus influenzae, Moraxella Catarrhalis, Staphylococcus aureus,
Streptococcus Pneumoniae
• Ciprofloxacine seulement si colonisation par Pseudomonas Aeruginosa établie et
germe sensible
• Si Pseudomonas Aeruginosa resistant aux quinolones, monothérapie iv
appropriée
MJ Harrison, Eur Respir Mon 2017
![Page 21: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/21.jpg)
Antibiothérapie: suite
• Pseudomonas: bi-thérapie iv recommandée si multi-résistance ou « patient likely
to require recurrent courses of antibiotics.. »:
• b-lactam + aminoglycoside
• Piperacilline/tazobactam et Colistine inhalée
• Meropenem ou Aztreonam et ceftazidime ou Piperacilline/tazobactam
• Ceftazidime en pompe
• MRSA: traiter avec 2 antibiotiques per os ou un agent iv
• Place des antibiotiques inhalés lors d’exacerbations aiguës débattue (3è ligne)
• Pas d’indication aux stéroïdes per os sauf si asthme ou BPCO associée
![Page 22: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/22.jpg)
5. Prise en charge post exacerbation
• Fonction de l’étiologie
Points stratégiques:
• Prévention des exacerbations: macrolides, AB inhalés
• Colonisation par Pseudomonas: éradication (stratégies), prévention des
exacerbations
• Colonisation par MOTT: identification, démonstration de l’évolutivité et de la
pathogénicité, traitements spécifiques à discuter avec spécialistes
• Physiothérapie
![Page 23: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/23.jpg)
Prise en charge: prévention des exacerbations
• Lors d’immunodéficience, traitements substitutifs
• Vaccination antigrippale, anti-pneumococcique
E Poverino et al; ERJ, 2017
![Page 24: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/24.jpg)
Eradication du Pseudomonas: quand? comment?
![Page 25: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/25.jpg)
Eva Polverino et al, ERJ 2017
![Page 26: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/26.jpg)
Eradication des Pseudomonas: options possibles..
E Poverino et al; ERJ, 2017 BTS guidelines, 2010
Very low quality of evidence….
![Page 27: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/27.jpg)
Prévention des exacerbations: macrolides
• EMBRACE study (Wong, Lancet, 2012): Azithromycine 3 x 500 mg/semaine vs placebo sur 6 mois chez 141 patients avec DDB: IRR: 0.38 (95%CI: 0.26-0.54)
• BAT trial (Altenburg J, JAMA 2013): Azithromycine 250 mg/jour vs placebo 12 mois, n=83: HR: 0.29 (95%CI: 0.16-0.51). 40% EI digestifs. 88% resistances aux macrolides dans le bras traité vs. 26%
• BLESS trial (Serisier et al, JAMA 2013): erythromycine 12 mois, vs placebo, n=107; IRR for exacerbations: 0.57, 95%CI: 0.42-0.77; modest decrease in rate of lung function decline
• Recommandation: Azithromycine 3 x 250 mg/semaine si colonisation par Pseudomonas et > 3 exacerbations/année
• Suivre: acouphènes, tests hépatiques, ECG et intervalle QT. Rechercher MOTT avant d’initier le traitement
![Page 28: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/28.jpg)
E Poverino et al; ERJ, 2017
![Page 29: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/29.jpg)
![Page 30: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/30.jpg)
Prévention des exacerbations: traitement inhalés
• Traitements inhalés: Colistine (2 x 1MU/jour), Tobramycine (TOBI: 2 x 300 mg/jour)
• Tester tolérance sous surveillance: ad 30% de bronchospasme
• Cave toxicité cumulée avec azithromycine (ototoxicité)
• Utilisation combinée possible (conditional recommendation, low quality evidence,
ERJ 2017)
![Page 31: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/31.jpg)
Physiothérapie
![Page 32: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/32.jpg)
Bronchiectasies non-CF et réhabilitation respiratoire
• 4 RCT, une étude méta-analyse, n=164, programmes de 8 sem.
• Bénéfices sur « shuttle test » et QVLS après le programme (8-12 sem), non
maintenus à 6 mois; effet + sur les exacerbations aiguës sur 12 mois
• Bénéfice additionnel de l’entraînement résistif inspiratoire?
• « No evidence of cross-infection »
Lee AL et al, Arch Phys Med Rehabil. 2017 Mandal P et al, Respir Med. 2012
BTS Guidelines, Thorax 2013; ATS Guidelines, CL Rochester, AJRCCM 2015
![Page 33: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/33.jpg)
Flutter
Cornet
Acapella
![Page 34: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/34.jpg)
Percussionnaire
Vest
![Page 35: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/35.jpg)
![Page 36: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/36.jpg)
Autres traitements préventifs et/ou symptomatiques
• CSI: pas recommandés sauf si asthme/ACOS associé
• SABA/LABA: peuvent être tentés si dyspnée selon EFR
• Dnase: non recommandé
• Mucolytiques: à considérer de cas en cas (weak evidence)
• Chirurgie: envisageable si maladie localisée, symptomatique, non évolutive,
sans maladie de système
![Page 37: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/37.jpg)
Autres traitements
• Qualité de vie très affectée par les DDB (SGRQ validé dans cette population)
• DAVI: à envisager si colonisation par Pseudomonas et exacerbations
répétées: permet traitements à domicile
• Attention à l’état nutritionnel , facteur de mauvais pronostic: évaluation
nutritionnelle et SNO/PEG
• VNI: parfois utile lors d’exacerbations ou au long cours
![Page 38: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/38.jpg)
Références
• British Thoracic Society Guidelines, Thorax 2010, MC Pasteur et al
• European Respiratory Guidelines for the management of non-CF bronchiectasis;
Eur Respir J, 2017; E Polverino et al.
• Primary care summary of the British Thoracic Society Guideline on the
management of non-cystic fibrosis bronchiectasis; Primary Care J 2011; Adam T
Hill et al.
• V Espinosa et al, Rev Med CH 2013
• Non-cystic fibrosis bronchiectasis: definition, severity and impact of pulmonary
exacerbations. Eur Respir Monogr 2017; S Finch et al.
![Page 39: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/39.jpg)
Merci pour votre attention..!
![Page 40: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/40.jpg)
Eradication des pseudomonas: 3 options possibles..
![Page 41: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/41.jpg)
Bilan étiologique: les co-morbidités « classiques » à évoquer
• Déficit en alpha-1-antitrypsine (rare, à chercher si emphysème associé)
• Mucoviscidose et maladie apparentées (test à la sueur; recherche de mutations du CFTR)
• RCUH, Crohn
• Polyarthrite rhumatoïde , LED
• Post infectieuses (coqueluche, bronchiolite ou infection sévère dans l’enfance, TB)
• Bronchiolite oblitérante post Tx (cellules souches, poumon..)
• (Pneumopathies interstitielles)
Lors de la recherche de mutations pour le gène CFTR, les laboratoires de génétique médicale proposent de tester en premier les 32 mutations les plus fréquentes retrouvées en Europe occidentale (coût en 2012 : environ CHF 450.–). Si cette première recherche est non conclusive et que la suspicion clinique est forte, on peut procéder à un séquençage complet (de tous les exons) du gène CFTR (coût : CHF 1600 à 2000.– environ).
![Page 42: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/42.jpg)
Traitement nebulisés
• Préférer un embout buccal, avec valve expiratoire
• Particules : 0.5 – 5µm
• Pas de mélange de substances; salbutamol disponible avant 1ères inhalations de Colisitine ou Tobramycine
• Durée max 10 min
• PARI Jet nebulizers (LC Sprint, LC Plus & LC Star) will deliver 2.5mL of saline solution in 5 to 8 minutes
• PARI eFlow
• …..
http://torontoadultcf.com/daily-living/it-better-use-mask-or-mouthpiece
![Page 43: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/43.jpg)
Outils pour améliorer la clearance mucociliaire
• Traitements inhalés: sérum physiologique, NaCl hypertonique 3%, 6%,
salbutamol
• Pression positive (VNI, IPPB)
![Page 44: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/44.jpg)
![Page 45: Exacerbations aigues lors de bronchiectasies · « The panel unanimously agreed the definition as: “a person with bronchiectasis with a deterioration in three or more of the following](https://reader033.vdocuments.us/reader033/viewer/2022043021/5f3d1de14f516c2f4c08e24f/html5/thumbnails/45.jpg)