Pediatric asthma treatment: What to do when international guideline recommendations do not agree.

BACKGROUND: There was a need for a solid asthma guideline in Mexico to update and unify asthma management. Because high-quality asthma guidelines exist worldwide, in which the latest evidence on asthma management is summarized, the ADAPTE approach allows for the development of a national asthma guideline based on evidence from already existing guidelines, adapted to national needs. OBJECTIVE: To fuse evidence from the best asthma guidelines and adapt it to local needs with the ADAPTE approach. METHODS: The Appraisal of Guidelines for Research and Evaluation (AGREE) II asthma guidelines were evaluated by a core group to select 3 primary guidelines. For each step of asthma management, clinical questions were formulated and replied according to (1) evidence in the primary guidelines, (2) safety, (3) Cost, and (4) patient preference. The Guidelines Development Group, composed of a broad range of experts from medical specialties, primary care physicians, and methodologists, adjusted the draft questions and replies in several rounds of a Delphi process and 3 face-to-face meetings, taking into account the reality of the situation in Mexico. We present the results of the pediatric asthma treatment part. RESULTS: Selected primary guidelines are from the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN), Global Initiative for Asthma (GINA), and Spanish Guidelines on the Management of Asthma (GEMA) 2015, with 2016 updates. Recommendations or suggestions were made for asthma treatment in Mexico. In this article, the detailed analysis of the evidence present in the BTS/SIGN, GINA, and GEMA sections on the (non) pharmacologic treatment of pediatric asthma, education, and devices are presented for 2 age groups: children 5 years or younger and children 6 to 11 years old with asthma. CONCLUSION: For the pediatric treatment and patient education sections, applying the AGREE II and Delphi methods is useful to develop a scientifically sustained document, adjusted to the Mexican situation, as is the Mexican Guideline on Asthma.

Global Asthma Network Phase I study in Mexico: prevalence of asthma symptoms, risk factors and altitude associations-a cross-sectional study.

BACKGROUND: Global Asthma Network (GAN) was established in 2012 as a development to the International Study of Asthma and Allergies in Childhood to improve asthma care globally. OBJECTIVE: To survey asthma, allergic rhinitis and atopic dermatitis in primary and secondary school children and to investigate and evaluate its prevalence, severity, management and risk factors in Mexico. METHODS: GAN Phase I is a cross-sectional, multicentre survey carried out in 15 centres corresponding to 14 Mexican cities throughout 2016-2019 using the validated Spanish language version of the GAN Phase I questionnaires. The questionnaires were completed by parents of 6-7-year-old primary school pupils (school children) and by 13-14-year-old adolescents. RESULTS: A total of 35 780 school children and 41 399 adolescents participated. Wheezing ever prevalence was 26.2% (95% CI 25.8% to 26.7%) in school children and 23.9% (95% CI 23.4% to 24.3%) in adolescents. The corresponding frequencies for current wheeze were 10.2% (95% CI 9.9% to 10.5%) and 11.6% (95% CI 11.2% to 11.9%). In school children, the risk factors for current wheeze were rhinitis (OR 4.484; 95% CI 3.915% to 5.134%) and rash symptoms (OR 1.735; 95% CI 1.461% to 2.059%). For adolescents, rhinitis symptoms (OR 3.492; 95% CI 3.188% to 3.825%) and allergic rhinitis diagnosis (OR 2.144; 95% CI 1.787% to 2.572%) were the most significant. For both groups, there was a negative relation with centres' sea level altitude higher than 1500 m above mean sea level (p<0.005). CONCLUSIONS: The most important risk factors for asthma symptoms in both age groups were the presence of rhinitis and rash symptoms or diagnosis. On the other hand, sea level altitude higher than 1500 metres was a protective factor.

[Chronic cough. Cough reflex hypersensitivity syndrome]. / Tos crónica. Síndrome de hipersensibilidad del reflejo de la tos.

The cough reflex is a protective mechanism of the airway; it avoids bronchoaspiration and its complications and, when it is altered, it can appear as a hypersensitivity syndrome; cough per se is the most common symptom for which medical consultation is sought. Chronic cough represents a public health problem with a high degree of morbidity; It represents a syndrome by itself, regardless of the underlying condition. Recent evidence suggests an abnormal and altered neurophysiologic process. Recent literature and new therapeutic mechanisms were reviewed. We are in the process of understanding the cough syndrome.

El reflejo de la tos es un mecanismo de protección de la vía respiratoria, evita la broncoaspiración y sus complicaciones; cuando está alterado puede manifestarse como un síndrome de hipersensibilidad. La tos per se es el síntoma más común por el que se consulta en la práctica médica. La tos crónica representa un problema de salud pública, con alto grado de morbilidad; representa un síndrome por sí mismo, sin importar la condición subyacente. Evidencia reciente sugiere un proceso neurofisiológico anormal y alterado. Se revisó literatura especializada y acerca de los nuevos mecanismos terapéuticos. Estamos en proceso de comprender el síndrome de la tos.

[Mexican Asthma Guidelines: GUIMA 2017]. / Guía Mexicana del Asma: GUIMA 2017.

BACKGROUND: The need for a national guideline, with a broad basis among specialists and primary care physicians was felt in Mexico, to try unifying asthma management. As several high-quality asthma guidelines exist worldwide, it was decided to select the best three for transculturation. METHODS: Following the internationally recommended methodology for guideline transculturation, ADAPTE, a literature search for asthma guidelines, published 1-1-2007 through 31-12-2015 was conducted. AGREE-II evaluations yielded 3/40 most suitable for transculturation. Their compound evidence was fused with local reality, patient preference, cost and safety considerations to draft the guideline document. Subsequently, this was adjusted by physicians from 12 national medical societies in several rounds of a Delphi process and 3 face-to-face meetings to reach the final version. RESULTS: Evidence was fused from British Thoracic Society Asthma Guideline 2014, Global Initiative on Asthma 2015, and Guía Española del Manejo del Asma 2015 (2016 updates included). After 3 Delphi-rounds we developed an evidence-based document taking into account patient characteristics, including age, treatment costs and safety and best locally available medication. CONCLUSIONS: In cooperation pulmonologists, allergists, ENT physicians, paediatricians and GPs were able to develop an evidence-based document for the prevention, diagnosis and treatment of asthma and its exacerbations in Mexico.

Antecedentes: Con el objetivo de unificar el manejo del asma en México se estructuró una guía clínica que conjunta el conocimiento de diversas especialidades y la atención en el primer nivel de contacto. Se seleccionaron 3 guías publicadas en el ámbito internacional para su transculturación. Métodos: Conforme a la metodología ADAPTE se usó AGREE II después de la búsqueda bibliográfica de guías sobre asma publicadas entre 2007 y 2015. Se fusionó la realidad local con la evidencia de 3/40 mejores guías. El documento inicial fue sometido a la revisión de representantes de 12 sociedades médicas en varias rondas Delphi hasta llegar a la versión final. Resultados: Las guías base fueron la British Thoracic Society Asthma Guideline 2014, la Global Initiative on Asthma 2015 y la Guía Española del Manejo del Asma 2015. Después de 3 rondas Delphi se desarrolló un documento en el que se consideraron las características de los pacientes según edad, costos de los tratamientos y perfiles de seguridad de los fármacos disponibles en México. Conclusión: Con la cooperación de neumólogos, alergólogos, otorrinolaringólogos, pediatras y médicos generales se llegó a un consenso basado en evidencia, en el que se incluyeron recomendaciones sobre prevención, diagnóstico y tratamiento del asma y sus crisis.

[Chronic rhinosinusitis in children]. / Rinosinusitis crónica en niños.

OBJETIVE: To review the existent literature regarding chronic rhinosinusitis in children. METHODS: PubMed search using the keywords: chronic sinusitis, chronic rhinosinusitis, chronic cough in children, persistent cough, gastroesophageal reflux in children, cystic fibrosis, ciliary diskinesia. Articles were selected based on their relevance to this review. RESULTS: Chronic rhinosinusitis in children and adults appear to have different etiology and therefore different diagnostic and treatment strategies. It is becoming more apparent that adult chronic rhinosinusitis has a relatively greater inflammatory component whereas childhood chronic rhinosinusitis has a relatively greater infectious component. This is secondary to immaturity of the pediatric immune system, the increased incidence of viral upper respiratory tract infections, the smaller ostia of the sinuses and adenoidal hypertrophy. Concentrations of eosinophils in adult mucosa are greater than those noted in children. There is a greater degree of collagen deposition and expansion of submucosal mucous glands in the adult sinus indicating more tissue remodeling and potentially greater irreversible scarring. Immune deficiencies, cystic fibrosis, and ciliary dyskinesia are more likely to occur in children. CONCLUSIONS: Careful history and physical examination, together with appropriate investigations, enable the clinician to make a correct diagnosis in the majority of cases of chronic rhinosinusitis. For the difficult cases the referral to a pediatric specialist in allergy, clinical immunology and respiratory diseases is warranted.

[Non-allergic chronic rhinitis]. / Rinitis crónica no alérgica.

OBJECTIVE: To review the existent literature regarding non-allergic rhinitis. DATA SOURCES: PubMed search was performed using the key words: non-allergic rhinitis, vasomotor rhinitis, irritant rhinitis, idiopathic rhinitis, chronic rhinopathy, nociceptive dysfunction, capsaicin, entopy. STUDY SELECTION: Articles were selected based on their relevance to this review. RESULTS: Chronic rhinitis affects up to 20% of the general population. The term rhinitis (inflammation of the nasal mucosal membrane) is used in daily practice for nasal dysfunction causing symptoms like nasal itching, sneezing, rhinorrhea, and or nasal blockage. When allergy, mechanical obstruction, and infections have been excluded as the cause of rhinitis, a number of poorly defined nasal conditions of partly unknown etiology and pathophysiology remain. The differential diagnosis of non-allergic noninfectious rhinitis is extensive. If the pathophysiology is unknown, the term idiopathic rhinitis is used as well as vasomotor rhinitis. This term has been recently questioned and the term non-allergic rhinopathy has been proposed with the subsequent definition and inclusion criteria delineated; other forms include irritative-toxic (occupational) rhinitis, hormonal rhinitis, drug-induced rhinitis, non-allergic rhinitis with eosinophilia syndrome, rhinitis due to physical and chemical factors, food-induced rhinitis, emotion-induced rhinitis, atrophic rhinitis. CONCLUSIONS: The number of patients with non-allergic, non-infectious rhinitis as a known cause or precipitant factor has increased in the last years. Nevertheless, 50% of the patients have to be classified as non-allergic rhinitis, known today as non-allergic rhinopathy. It's important for this group of patients to be evaluated by an expert in Rhinology and Allergy to determine the best possible treatment.

[Chronic cough in pediatrics: Review and analysis]. / Tos crónica en pediatría. Revisión y análisis.

OBJECTIVE: To review and to analyze the existing literature regarding chronic cough in children. MATERIAL AND METHODS: We searched published articles in PubMed using the key words: cough, chronic cough, chronic cough in children, persistent cough, gastroesophageal reflux in children. RESULTS: Cough in children is common; the majority of cases reflect respiratory infections. Cough is rarely associated to a serious disorder. All children with cough persisting for more than 8 weeks should be evaluated. A careful history, physical examination, chest x-ray, and spirometry (in an able child) are recommended for all children with chronic cough. If a diagnosis is no evident (nonspecific cough), then an approach based on characterizing the cough as "wet" or "dry" is helpful. In each case, specific etiology-based treatment is recommended when possible; otherwise, a therapeutic trial is indicated with inhaled corticosteroids (ICS) for children with dry cough (for possible asthma) and antibiotics for wet cough (for possible protracted bacterial bronchitis [PPB] or sinusitis). The treatment should be reviewed within the specified time frame for normal response. If no effect is obvious, the treatment should be stopped and alternative diagnosis considered. Multiple etiologies may need to be treated concomitantly. Every effort should be made to identify the underlying cause. Data suggests potential harmful effects of medications used for symptomatic relief of acute or chronic cough in children. CONCLUSIONS: Medical history and physical examination, together with appropriate investigations allow the correct diagnosis of chronic cough. The diagnostic approach is summarized in Figures 1 and 2. Most cases can be managed with this algorithm. For the difficult, complex and rare cases referral to a Pediatric specialist in Allergy, Clinical Immunology and Respiratory Diseases is warranted.

[Leukotrien antagonists in the treatment of allergic rhinitis and comorbidities]. / Antagonistas de leucotrienos en el tratamiento de la rinitis alérgica y enfermedades concomitantes.

Leukotrienes comprise a family of products of the 5-lipoxigenase pathway of arachidonic acid metabolism. The cysteinil leukotrienes C4, D4 and E4 account for the biologic activity that was previously termed "slow-reacting substance of anaphylaxis". The proinflammatory effects of cysteinil leukotrienes (cys LTs) have been well described in asthma and rhinitis. The cys LTs induce broncospasm (1,000 times more potent than histamine), edema, mucus, hypersecretion, attract inflammatory cells like eosinophils, increase airway hyperreactivity, vascular leakage, and stimulate takikinins. The leukotriene synthesis can be inhibited in two different places; through inhibition of 5 lipooxigenase activating protein (FLAP) in the 5 lipooxigenase pathway, with the drug Zyleuton, or blocking the cysLT1 receptor with the drugs Montelukast, Pranlukast, Zafirlukast. The cysLTs play an important role in pathophysiology of allergic rhinitis and comorbid diseases like rhinosinusitis and nasal polyposis. Antileukotrienes are prescribed in the treatment of allergic rhinitis. Allergic rhinitis is a complex IgE inflammatory disease of the upper airways. It is the most common allergic disease ocurring in 10 to 20% of adults and up to 30% of children. It may be seasonal or perennial, intermittent or persistent. Sneezing, itching, watery rhinorrea and nasal obstruction are classic symptoms. Ocular itching, lacrimation and redness also occur frequently as almost 50% of the patients also have allergic conjunctivitis. Allergic rhinitis may be mild, moderate or severe disease. It may impair cognition, school and work performance. It affects productivity, behavior and mood changes, causes sleep disturbance and diminish the patient's quality of life. Allergic rhinitis is a common comorbid condition with asthma, sinusitis, otitis media, nasal polyposis and recurrent respiratory infections. The purpose of this rewiew article is to know the importante of leukotrienes, its receptors and the clinical efficacy of leukotriene antagonists in allergic rhinitis and comorbid diseases.

[Intrasal corticosteriods prescription to allergic rhinoconjunctivitis and rhinosinusitis during pediatric ages]. / Prescripción de corticosteroides intranasales para la rinoconjuntivitis alérgica y rinosinusitis en la edad pediátrica.

The different diseases that affect the upper respiratory tract, like allergic rhinitis, rhinoconjunctivitis, and rhinosinusitis have inflammation as their main pathophysiological component. Affects approximately 25% of the adults and 40% of the children. Intranasal corticosteroids (INSs) are considered the most effective treatment for the management of allergic rhinoconjunctivitis. Unlike antihistamines or antileukotrienes, INSs have a more profound effect on nasal congestion and the related sleep disturbance and daytime somnolence resulting from nasal congestion that affect their everyday quality of life. We review INSs mechanism of action, pharmacological properties of the different INSs, their therapeutic use and give our suggestions for their proper use.

[When the cause of dyspnea is on larynx. Asthma of difficult control, resistant to treatment? Vocal cords dysfunction? or Both?]. / Cuando la causa de la disnea se encuentra en la laringe. Asma de dificil control, resistente al tratamiento? Disfunción de las cuerdas vocales? o Ambas?

Dyspnea is a symptom whose diagnosis requires the exclusion of other diseases with which it can be confused, such as asthma and a variety of pulmonary and heart diseases. Dyspnea originated in the larynx may occur due to obstruction by a tumor or other affections in situ, interfering the airway, such as: edema by infections or inflammatory processes, a traumatism, an abnormal movement of the larynx structures, such as the inappropriate or absent of the vocal cords or the laryngospasm. Severity of larynx dyspnea may be to mild to acute, risking the life. This paper reviews the normal laryngeal function and the anatomic, obstructive, and functional disorders that can lead to dyspnea. Some suggestions are also made to determine the cause and treat these diseases.

[Macrolides. Antiinflammatory and immunomodulator effects. Indication in respiratory diseases]. / Macrólidos. Efectos antinflamatorios e inmunomoduladores. Indicación en enfermedades respiratorias.

This article reviews the basics and the clinical implications of the immunomodulatory effects of macrolides in different respiratory diseases. In addition to their antiinfective properties, some macrolides possess immunomodulatory effects (14 member ring). These macrolides have been used successfully to treat diffuse panbronchiolitis, a progressive inflamatory disease and may be very useful in the treatment of asthma, chronic bronchitis, chronic sinusitis, nasal polyps, otitis media with effusion, cystic fibrosis and bronchiectasis. We present the basic and clinical work supporting its chronic use. We will need future double blind controlled trials to determine the long term efficacy of macrolides for the treatment of chronic inflammatory airway diseases, as well as development of resistance, how to improve side effects ratio and the duration of effects after cessation of treatment.

[Allergic rhinitis. Coexistent diseases and complications. A review and analysis]. / Rinitis alérgica. Enfermedades coexistentes y complicaciones. Revisión y análisis.

Allergic rhinitis (AR) is rarely found in isolation and needs to be considered in the context of systemic allergic disease associated with numerous comorbid disorders, including asthma, chronic middle ear effusions, sinusitis, and lymphoid hypertrophy with obstructive sleep apnea, disordered sleep, and consequent behavioral and educational effects. The coexistence of allergic rhinitis and asthma is complex. First, the diagnosis of asthma may be confused by symptoms of cough caused by rhinitis and postnasal drip. This may lead to either inaccurate diagnosis of asthma or inappropriate assessment of asthma severity with over treatment of the patient. The term "cough variant rhinitis" is therefore proposed to describe rhinitis that manifest itself primarily as cough that results from postnasal drip. Allergic rhinitis, however, has also a causal role in asthma; it appears both to be responsible for exacerbating asthma and to have a role in its pathogenesis. Postnasal drip with nasopharyngeal inflammation leads to a number of other conditions. Thus sinusitis is a frequent extension of rhinitis and is one of the most frequently missed diagnoses. Allergen exposure in the nasopharynx with release of histamine and other mediators can cause Eustachian tube obstruction possibly leading to middle ear effusions. Chronic allergic inflammation of the upper airway causes lymphoid hypertrophy with prominence of adenoidal and tonsillar tissue. This may be associated with poor appetite, poor growth, obstructive sleep apnea, mouth breathing, pharyngeal irritation and dental abnormalities. Allergic rhinitis is therefore part of a spectrum of allergic disorders that can profoundly affect the well being and quality of life of a child. Prospective cohort studies are required to assess the disease burden caused by allergic rhinitis in childhood, its consequences due to delay in diagnosis and treatment, and to further assess the potential educational impairment that may result. Because allergic rhinitis is part of a systemic disease process, its diagnosis and management require a coordinated approach by the specialist in allergy-immunology-rhinology rather than a fragmented, organ based approach. There are other clinical presentations such as recurrent infections of the upper respiratory tract, as well as pharyngeal and laryngeal disorders.

Disfunción del olfato / Disfunction of the sense of smell

Objetivo: reportar los resultados obtenidos con el abordaje sistematizado (fisiopatológico, de diagnóstico y tratamiento) de la disfunción del olfato que puede afectar la vida del paciente en forma significativa. Material y método: se evaluaron 58 pacientes que acudieron a la clínica con alteraciones en la olfación o el gusto, o ambos. El protocolo incluye un cuestionario orientado, pruebas de identificación de olores y umbral olfatorio, rinomanometría, histograma nasal, estudio radiológico simple de las vías respiratorias superiores y senos paranasales, además de tomografía axial computada y endoscopia. Resultados: la causa más frecuente de la disfunción olfatoria fue la obstrucción mecánica debida a procesos inflamatorios, como sinusitis crónica y poliposis nasal, las cuales obstruyen el nicho olfatorio como complicación; de los 58 pacientes, 48 por ciento pertenecieron a este grupo. Esta enfermedad inflamatoria se dividió, a su vez, en alergia pura 25 por ciento, infecciosa 21 por ciento y patrón mixto 54 por ciento. Las pruebas olfatorias mostraron hiposmia severa. En el análisis general el resto de la disfunción olfatoria se clasificó como postviral en 20 por ciento, postraumática en 12.1 por ciento, un grupo misceláneo 8.6 por ciento, provocada por toxinas 6-9 por ciento, quedando un grupo de causa idiopática en 3.4 por ciento.

Rinofaringolaringoscopia flexible en la evaluación de pacientes con problemas alérgicos y de vías respiratorias altas / Rhinofaringoscopy flexible in the evaluation of patient for problem. allergics upper respirator arrways

La rinofaringolaringoscopia flexible es un procedimiento muy útil y valioso en nuestra práctica diaria, capaz de aportar hasta 60 por ciento de información adicional en el diagnóstico y abordaje de pacientes con enfermedad alérgica y de vías respiratorias superiores. Se describe el procedimiento endoscópico en nuestro Instituto privado así como los hallazgos más importantes en 423 pacientes. El 49 por ciento presentó alguna anormalidad en la mucosa nasal y meato medio, sitio relacionado con el drenaje de senos paranasles. En 23 pacientes encontramos alteraciones en los cornetes, cambios polipoideos, degeneración o presencia de concha bulosa. Un gran porcentaje de esta afección no se diagnostica mediante el examen convencional. El 7 por ciento presentó cambios significativos en el área relacionada con el epitelio olfatorio, edema e inflamación con la consecuente alteración en el olfato y gusto. 56 pacientes presentaron inflamación e hipertrofia en el complejo adenoideo, y la mitad de éstos, 28 pacientes con algún grado de obstrucción del tubo faringó-auditivo (trompa de Eustaquio). En el área laríngea, 58 pacientes (14 por ciento) tuvieron anormalidades, predominando cambiso inflamatorios y edema en epiglotis y glotis (8 por ciento), secundaria al mal uso de la voz, requiriendo terapia de lenguaje y en 4 por ciento patología de cuerdas vocales, predominando los pólipos y la parálisis. Encontramos dos pacientes con carcinoma que requirieron biopsia, y tratamiento específico. Es un procedimiento que puede aprenderse fácilmente en 2 o 3 sesiones y que repercutirá directamente en nuestra capacidad para diagnosticar enfermedad de la vía aérea superior

Estudio del niño con obstrucción recurrente de las vías respiratorias superiores / The study of the children wiht recurrent upper airway obstruction

Antecedentes. La indagación sistémica de la obstrucción recurrente de las vías respiratorias superiores en niños debe basarse en una historia clínica completa, el uso adecuado de los estudios de laboratorio, y procedimientos diagnósticos que ayuden a identificar las causas más comunes de obstrucción y su interrelación con otras afecciones como: alergia nasal, rinosinusitis y adenoiditis con o sin hipertrofia significativa. Objetivo. Proponer un protocolo de estudio del paciente con obstrucción recurrente de las vías respiratorias utilizado en el Instituto Privado de Alergia, Inmunología y Vías Respiratorias. Material y método. Se estudió en forma prospectiva una cohorte de 117 pacientes en edad pediátrica, con manifestaciones clínicas de obstrucción recurrente de las vías respiratorias superiores. Resultados. El 75 por ciento de los pacientes estudiados tuvieron un patrón histológico sugerente de alergia nasal e infección interecurrente siguiendo el método descrito por A. Jalowayski con el uso de Thinoprobe. Se comprobó que el uso de la radiología convencional para el diagnóstico de hipertrofia-hiperplasia del tejido adenoideo es útil y orienta al diagnóstico primario en 75 por ciento de los pacientes. Conclusiones. El procedimiento endoscópico de las vías aéreas superiores es la prueba más sensible y específica para valorar la situación real del tejido adenoideo y su relación con la cavidad nasal