[Management of Primary Ciliary Dyskinesia]. / Management der Primären Ciliären Dyskinesie.

Primary Ciliary Dyskinesia (PCD, MIM 242650) is a rare, hereditary multiorgan disease characterized by malfunction of motile cilia. Hallmark symptom is a chronic airway infection due to mucostasis leading to irreversible lung damage that may progress to respiratory failure. There is no cure for this genetic disease and evidence-based treatment is limited. Until recently, there were no randomized controlled trials performed in PCD, but this year, data of the first placebo-controlled trial on pharmacotherapy in PCD were published. This cornerstone in the management of PCD was decisive for reviewing currently used treatment strategies. This article is a consensus of patient representatives and clinicians, which are highly experienced in care of PCD-patients and provides an overview of the management of PCD. Treatments are mainly based on expert opinions, personal experiences, or are deduced from other lung diseases, notably cystic fibrosis (CF), COPD or bronchiectasis. Most strategies focus on routine airway clearance and treatment of recurrent respiratory tract infections. Non-respiratory symptoms are treated organ specific. To generate further evidence-based knowledge, other projects are under way, e. g. the International PCD-Registry. Participating in patient registries facilitates access to clinical and research studies and strengthens networks between centers. In addition, knowledge of genotype-specific course of the disease will offer the opportunity to further improve and individualize patient care.

Calprotectin as a New Sensitive Marker of Neutrophilic Inflammation in Patients with Bronchiolitis Obliterans.

INTRODUCTION: Bronchiolitis obliterans (BO) is a chronic disease in which persistent inflammation leads to obstruction and obliteration of the small airways. The aim of this study was to evaluate the value of calprotectin as an inflammatory marker in induced sputum. METHODS: Twenty-eight patients suffering from BO and 18 healthy controls were examined. Lung function was measured by spirometry, body plethysmography, and lung clearance index (LCI). The induced sputum was obtained, cell counts were performed, and cytokines were measured using cytometric bead array (CBA). Calprotectin was quantified in the sputum and serum samples using commercially available sandwich ELISA. RESULTS: Spirometry parameters including forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and maximum expiratory flow rate at 25% vital capacity (MEF25) were significantly lower in BO patients than in healthy controls, whereas the reserve volume (RV), RV to total lung capacity ratio (RV/TLC), and LCI were significantly increased. In sputum, calprotectin levels, neutrophils, and IL-8 were significantly elevated. Calprotectin levels correlated strongly with IL-8 and other biomarkers, neutrophils FEV1 and MEF25. In serum, calprotectin was significantly diminished in BO patients compared to controls. CONCLUSION: Lung function is severely impaired in BO patients. Calprotectin is significantly elevated in the sputum of BO patients and reflects ongoing neutrophilic inflammation.

[Lung Function, Lung Clearance Index und Bronchial Inflammation in Children and Adolescents with Bronchiolitis obliterans]. / Lungenfunktion, Lung Clearance Index und bronchiale Entzündung bei Kindern und Jugendlichen mit Bronchiolitis obliterans.

INTRODUCTION: Bronchiolitis obliterans (BO) is a rare and severe pulmonary disease which can occur due to airway infection or as a result of stem cell or lung transplantation. Our goal was to study the lung function and airway inflammation among BO patients. Furthermore, we examined the potential of the lung clearance index (LCI) for BO diagnostics among that group. METHODS: 16 BO patients (age: 16.7; 9.6 - 25.3 years) and 17 healthy controls (age: 16.6; 7.6 - 25.0 years) participated in the study. Lung function parameters (FVC, FEV1, MEF25, RV und RV/TLC) as well as airway reversibility after administration of 400 µg salbutamol was investigated. The lung clearance index was determined using the multiple-breath washout method (MBW). Additionally, induced sputum was analyzed for cytology and cytokine levels (IL-1ß, IL-6, IL-8, TNF-α) using the cytometric bead array (CBA). RESULTS: BO patients had significantly lower FVC, FEV1 and MEF25 but increased RV and RV/TLC. Airway reversibility was observed in 3 patients. The LCI was significantly higher among BO patients compared to the healthy control group (median 10.24 vs. 7.1). Apart from a massive airway inflammation indicated by elevated numbers of total cells and neutrophils, the CBA analysis showed increased levels of IL-6 and IL-8 (p < 0.01). DISCUSSION: In BO patients, lung function in childhood and adolescence is severely impaired. Furthermore, we were able to demonstrate the sensitivity and reproducibility of LCI and its value for the evaluation of small airway obstruction. In induced sputum, a neutrophil-dominated airway inflammation is detectable.

Omalizumab effectively protects against early and late allergic responses in asthma after 4 weeks.

BACKGROUND: Omalizumab is licensed for therapy in severe allergic asthma with an effect demonstrated after 8 weeks or longer treatment. As new applications for omalizumab demand precise knowledge of the onset of effects, the objective of this study was to determine the time course of the early (EAR) and late allergic reaction (LAR). MATERIALS AND METHODS: Ten patients (IgE>300 IU/mL and <700 IU/mL) with a significant response to allergen challenge were treated with omalizumab according to the approved dosing table. Bronchial allergen provocations (BAP) were repeated at weeks 1, 2, 4, and 8. RESULTS: EAR was significantly reduced after 4 weeks (ΔFEV1 28% vs 11%; P<.001), eNO (86 vs 53 ppb; P<.05) and basophil activation after 2 weeks (CD63 expression 79% vs 32%, P<.05) and LAR already after 1 week (ΔFEV1 26% vs 13%, P<.05). CONCLUSION: These results demonstrate the onset of protective effects earlier than previously determined, potentially improving seasonal utilization and combination with immunotherapy.

[Quality of life for adolescents with vocal cord dysfunction]. / Lebensqualität bei jugendlichen mit vocal cord dysfunction.

BACKGROUND: Vocal cord dysfunction (VCD) is a functional breathing disorder. A psychosomatic aetiology has been discussed and associations with depression, anxiety disorders, and social stress have been reported. We have undertaken a screening of behavioural and emotional problems in adolescent patients using standardised questionnaires. METHODS: Thirty-one patients (8 - 16 years) with the clinical suspicion of VCD were investigated using the Youth-Self-Report (YSR/11 - 18) and for the assessment of the parents we used the analoguous Child-Behaviour-Checklist (CBCL/6 - 18). YSR and CBCL contain two sub-areas: (a) competence scales that measure the child's participation in activities, social skills and school achievements and (b) items that contain subscales for emotional problems such as depressive and anxiety symptoms, conduct problems such as oppositional defiant problems and aggressive behaviour, social problems and physical complaints. RESULTS: On average, the features of VCD patients were not significantly different from those of the reference population. But we did observe tendencies of psychological problems (YSR 16.7 %, CBCL 20 %) compared with the standard (2 %) in the syndrome scales of both questionnaires Adolescents reported particularly more internalising disorders such as social retreat, physical complaint and anxiety and depressive symptoms. The parents reported more often "physical complaints" (13.3 %) and "aggressive behaviour" (10 %). CONCLUSIONS: We found tendencies of psychological strain, mainly social retreat, physical complaints and anxiety and depressive symptoms. Further investigations should focus on those emotional problems as well as on psychosomatically caused physical problems. Personality and psychological stress of the parents should be included in the investigation in order to evaluate the reports of the parents on higher aggressive behaviour and enhanced physical problems of their children in relation to their own psychological strain. We suggest family therapies, family counselling, or parental coaching as a therapeutic approach.

Lipid-Laden Alveolar Macrophages and pH Monitoring in Gastroesophageal Reflux-Related Respiratory Symptoms.

Lipid-laden alveolar macrophages and pH monitoring have been used in the diagnosis of chronic aspiration in children with gastroesophageal reflux (GER). This study was conducted to prove a correlation between the detection of alimentary pulmonary fat phagocytosis and an increasing amount of proximal gastroesophageal reflux. It was assumed that proximal gastroesophageal reflux better correlates with aspiration than distal GER. Patients from 6 months to 16 years with unexplained recurrent wheezy bronchitis and bronchial hyperreactivity, or recurrent pneumonia with chronic cough underwent 24-hour double-channel pH monitoring and bronchoscopy with bronchoalveolar lavage (BAL). Aspiration of gastric content was determined by counting lipid laden alveolar macrophages from BAL specimens. There were no correlations between any pH-monitoring parameters and counts of lipid-laden macrophages in the whole study population, even when restricting analysis to those with abnormal reflux index expressing clinically significant GER. Quantifying lipid-laden alveolar macrophages from BAL in children with gastroesophageal-related respiratory disorders does not have an acceptable specificity to prove chronic aspiration as an underlying etiology. Therefore, research for other markers of pulmonary aspiration is needed.

[The repeatability of forced expiratory manoeuvres in 4- to 6-year-old children with intermittent bronchial asthma in healthy and in exacerbated status]. / Reproduzierbarkeit der FEV1 bei Kindern von 4 bis 6 Jahren mit intermittierendem Asthma bronchiale im beschwerdefreien sowie im Beschwerdeintervall.

INTRODUCTION: The question about the repeatability of forced expiratory manoeuvres in childhood lung function testing is of scientific and clinical interest. The following study investigated to what extent children ≥ 4 to < 7 years of age with intermittent bronchial asthma are able to produce reproducible lung function measurements on the one hand in the healthy status and on the other hand in an exacerbated status. METHOD: 64 children at the age of ≥ 4 to < 7 years with intermittent preschool bronchial asthma performed lung function measurements in the healthy status and again in an exacerbated status. FEV (1) values from the measurements were analysed according to ATS/ERS guidelines concerning repeatability. RESULTS: According to the new ATS/ERS guidelines 74.6 % of the children could perform at least 2, and 59.3 % could perform 3 repeatable measurements in the healthy status. In the exacerbated status this was 87.5 % and 68.8 %, respectively. There were no significant differences between the healthy and the exacerbated status and between the age groups. Compared to former repeatability criteria, children of this age group can perform significantly more reproducible measurements (p < 0.0001). CONCLUSION: The ATS/ERS guidelines from 2007 simplify the repeatability of forced expiratory manoeuvres in children at ≥ 4 to < 7 years of age compared to the former criteria. Repeatability is not reduced in the exacerbated status. 74.6 % of children in this age group can produce repeatable lung function measurements.

Tolerance induction after specific immunotherapy with pollen allergoids adjuvanted by monophosphoryl lipid A in children.

Specific immunotherapy (SIT) is a well-established and clinically effective treatment for allergic diseases. A pollen allergoid formulated with the T helper type 1 (Th1)-inducing adjuvant monophosphoryl lipid A (MPL) facilitates short-term SIT. Little is known about mechanisms of tolerance induction in this setting. In a prospective study, 34 patients allergic to grass pollen (25 male, nine female, median age 10.2 years) received a total of 44 SIT courses (20 in the first, 24 in the second) with MPL-adjuvanted pollen allergoids. Immunogenicity was measured by levels of specific immunoglobulin G (IgG(grass)) and IgG4(grass) by antibody blocking properties on basophil activation, and by induction of CD4(+), CD25(+) and forkhead box P3 (FoxP3(+)) regulatory T cells (T(reg)). Specific IgG and IgG4 levels increased only slightly in the first year of SIT. In the second year these changes reached significance (P < 0.0001). In keeping with these findings, we were able to show an increase of T(reg) cells and a decreased release of leukotrienes after the second year of treatment. In the first year of treatment we found little evidence for immunological changes. A significant antibody induction was seen only after the second course of SIT. Short-course immunotherapy with pollen allergoids formulated with the Th1-inducing adjuvant MPL needs at least two courses to establish tolerance.

Safety and immunogenicity of a cluster specific immunotherapy in children with bronchial asthma and mite allergy.

BACKGROUND: Cluster specific immunotherapy (SIT) is a modern form of allergen immunotherapy allowing safe administration of high allergen doses in a short time interval compared to classic SIT. In the current study, we investigated the safety profile and immunological effect of cluster SIT in children with allergic asthma due to house dust mite allergy. METHODS: A total of 34 children (6-18 years) with allergic asthma were assigned to cluster (n = 22) or classic SIT (n = 12). To achieve a maintenance dose of allergen extract, cluster patients received 14 injections of house dust mite allergen within 6 weeks, whereas the classic SIT group received 14 injections within 14 weeks. Safety was monitored by recording adverse events. Immunogenicity was measured by specific IgG(Mite) and IgG4(Mite), by antibody-blocking properties on basophil activation, and by the T cell subset transcription factors Foxp3, T-bet, and GATA-3. RESULTS: There were no significant differences in local and systemic side effects between the two groups. In the cluster group, serum levels of specific IgG(Mite) (p < 0.001) and specific IgG4(Mite) (p < 0.001) significantly increased after 8 weeks, while it took 12 weeks in the classic SIT group. These data were confirmed by blocking CD63 expression as well as release of cysteinyl leukotrienes after in vitro basophil stimulation. No differences in transcription factor expression were found in the two groups. CONCLUSION: Cluster SIT is safe in children. Additionally, our data demonstrated an even more rapid induction of specific immune tolerance. Cluster SIT is an attractive alternative to conventional up-dosing schedules with fewer consultations for the patients.

[Effects of active and passive smoking on the health of children and adolescents]. / Auswirkungen des Aktiv- und Passivrauchens auf die Gesundheit von Kindern und Jugendlichen.

Tobacco abuse is especially a public health problem among children and teenagers in Germany. While the proportion of adolescents smoking regularly was 18% in 1997, this has increased to more than 30% in 2001. The high impact of peer groups in young people aggravates the development of smoking habits. Furthermore, an addiction to nicotine develops mainly before the age of 20 (80% of all adults smokers have started as teenagers). Early and continued damage to health will result in long-term sequelae due to immaturity of the organs. Fortunately, the proportion of smoking adolescents has decreased in the last few years. Besides the well known effects of active smoking, children are especially endangered by environmental tobacco smoke (ETS). Exposure to cigarette smoke during pregnancy is directly correlated to premature rupture of the membranes, premature birth, delayed foetal development, and reduced lung function. Children are suffering from impairments of their health not only due to ETS exposure in utero but also after birth (e. g., diseases of upper and lower airways, delayed physical and mental development). Therefore, the prevention of active and passive smoking must be intensified and should consider the special situation of children and adolescents.

Montelukast as add-on therapy to beta-agonists and late airway response.

The present study investigated whether single-dose oral leukotriene receptor antagonists as add-on therapy to short-acting beta-agonists, immediately after allergen challenge, block the late-phase airway response. In total, 35 mild asthmatics (mean age 24 yrs, 19 males) sensitised for house dust mites underwent two courses of bronchial allergen challenge. After the early allergic response (EAR), subjects received salbutamol once and were randomly assigned to either 10 mg of montelukast or placebo (double-blind crossover). To identify a late allergic response, forced expiratory volume in one second (FEV(1)) was monitored over the following 8 h. Baseline exhaled nitric oxide (NO) was determined ahead of each allergen challenge. Baseline NO levels differed significantly depending on the reaction to allergen challenge. In total, 12 subjects showed no significant response, 11 only showed an EAR, and 12 had a dual response and underwent further analysis. The area under the FEV(1) time-response curve 3-8 h after bronchial allergen challenge was -0.77+/-1.68 from the pre-challenge values on montelukast compared with -2.47+/-1.32 on placebo. The baseline exhaled NO fraction of subjects without an EAR was significantly lower than of those presenting a dual response. The results of the present study demonstrate that single-dose leukotriene receptor antagonists given orally right after the early allergic response can significantly inhibit the late allergic response after bronchial allergen challenge.

Impaired interferon-gamma production in response to live bacteria and Toll-like receptor agonists in patients with ataxia telangiectasia.

Ataxia telangiectasia (AT) is a pleiotropic autosomal recessive neurodegenerative disorder with associated immunodeficiency and cancer predisposition, caused by mutational inactivation of the ATM gene. Early death usually results from lymphoreticular malignancy or recurrent, chronic respiratory infections. Immune deficiency of AT patients is heterogeneous and involves both humoral and cellular responses. Reports on the number and integrity of immunocompetent cells in AT are conflicting. In the early phase of infection, the interleukin (IL)-12/interferon (IFN)-gamma axis plays a crucial role in first-line defence against pathogens. In a whole blood assay we studied the IL-12/IFN-gamma axis in the immune response of AT cells to the Toll-like receptor agonists lipopolysaccharide and heat-killed Staphylococcus aureus, as well as whole live M. bovis bacille Calmette-Guérin (BCG). The function of AT antigen-presenting cells was normal in terms of IL-12 production, while IFN-gamma production by T and natural killer (NK) cells was severely impaired, even in the presence of adequate co-stimulation by exogenous IL-12.

Effect of anti-immunoglobulin E on nasal inflammation in patients with seasonal allergic rhinoconjunctivitis.

BACKGROUND: Binding of allergens to IgE on mast cells and basophils causes release of inflammatory mediators in nasal secretions. OBJECTIVE: The combined effect of specific immunotherapy (SIT) and omalizumab, a humanized monoclonal anti-IgE antibody, on release of eosinophilic cationic protein (ECP), tryptase, IL-6, and IL-8 in nasal secretion was evaluated. METHODS: Two hundred and twenty five children (aged 6-17 years) with a history of seasonal allergic rhinoconjunctivitis induced by birch and grass pollen were randomized into four groups: either birch- or grass-pollen SIT in combination with either anti-IgE or placebo. Complete sets of nasal secretion samples before treatment Visit 1 (V1), during birch- (V2) and grass (V3)-pollen season and after the pollen season (V4) were collected from 53 patients. RESULTS: A significant reduction in tryptase only was seen in the anti-IgE-treated group at V2 (P<0.05) and V4 (P<0.05) compared with the placebo group. During the pollen season, patients with placebo showed an increase of ECP compared with baseline (V2: +30.3 microg/L; V3: +134.2 microg/L, P< 0.005; V4: +79.0 microg/L, P< 0.05), and stable levels of tryptase, IL-6 and IL-8. Treatment with anti-IgE resulted in stable ECP values and a significant decrease of tryptase compared with V1 (baseline): V2: -80.0 microg/L (P< 0.05); V3: -56.3 microg/L, which persisted after the pollen season with V4: -71.6 microg/L (P< 0.05). After the pollen season, a decrease of IL-6 was observed in both groups (V4 placebo group: -37.5 ng/L; V4 anti-IgE group: -42.9 ng/L, P< 0.01). CONCLUSION: The combination of SIT and anti-IgE is associated with prevention of nasal ECP increase and decreased tryptase levels in nasal secretions.

Safety and tolerability of methacholine challenge in infants with recurrent wheeze.

Bronchial hyperreactivity (BHR) is a key feature of asthma, but measurement can usually not be achieved in infants with standard lung function tests. We investigated the safety and tolerability of methacholine challenge in infants with recurrent wheezing episodes. 78 methacholine challenges in 51 sedated infants aged 12-36 months with recurrent wheezing episodes were performed. Methacholine challenge was stopped when clinical signs (coughing, wheezing, or cyanosis) or a drop of oxygen saturation (SPO2) of at least 5% or a drop of transcutaneous oxygen tension (PtcO2) of at least 0.8 kPa or an increase of resistance (RrsSO), of 50% by single occlusion technique were observed. Prior to methacholine challenge, all children were symptom-free with a mean SPO2 of 97.4% (SD 1.80%). In 48 cases (61.5%), no clinical sign was observed, 17 (21.8%) coughed, and 13 (16.7%) wheezed. A mean reduction of SPO2 of 5.0% (SD 3.89%) for the entire population was observed. In 15 of 78 cases, a decrease of SPO2 <90% occurred. This SPO2 drop was short-lasting and resolved spontaneously or after bronchodilator inhalation. Infants whose SPO2 dropped <90% showed a greater increase of RrsSO compared to infants who did not drop <90% (133% vs. 65% RrsSO increase, p<0.001). Methacholine challenge, using a combination of clinical observation, monitoring of SPO2 and PtcO2, and airway resistance using the single-occlusion technique, is a safe and tolerable tool to measure the BHR in infants with recurrent wheezing episodes.