Asma en pediatría: claves para su diagnóstico y tratamiento según evidencia basada en el paciente / Patient-oriented evidence based essentials that matters for management of children with asthma

Asthma is one of the most prevalent chronic diseases in childhood. Diagnosis is still controversial in young patients. Misdiagnoses will delay the start of treatment. Several phenotypes are described, but these vary during the course of the disease, or can coexist. This article describes the key points to achieve an accurate clinical diagnosis characteristic phenotypes, and basic therapeutic strategies.

Siendo el asma una de las enfermedades crónicas de mayor prevalencia en pediatría, su diagnóstico aún es controversial en los pacientes de corta edad. En ocasiones este se confunde, lo que posterga el inicio del tratamiento adecuado. Se han descrito diversos fenotipos, sin embargo, estos pueden variar durante la evolución de la enfermedad, o pueden coexistir. Se describen los puntos esenciales para lograr un diagnóstico clínico certero, los fenotipos característicos, y las estrategias terapéuticas básicas.

Diagnóstico diferencial de la tos crónica en pediatría / Differencial diagnosis of chronic cough in children

Chronic cough is a common cause of outpatient consultation. It is a source of distress for patients and parents, and in some cases it resolves spontaneously, without finding etiology. Professor Miles Weinberger emphasizes the importance of exhaustive medical record to characterize cough and associated signs, allowing us to identify typical patterns of some diseases.

La tos crónica es una causa frecuente de consulta a nivel ambulatorio. Es motivo de angustia para pacientes y padres, y en algunos casos se resuelve espontáneamente, sin lograr precisar su etiología. El Profesor Miles Weinberger destaca la importancia de realizar una acuciosa historia clínica para caracterizar la tos y su signología asociada, lo que permite identificar patrones típicos de algunas enfermedades.

Protracted bacterial bronchitis in young children: association with airway malacia.

OBJECTIVE: To examine associated findings and clinical outcome in young children with prolonged cough, wheeze, and/or noisy breathing in whom high colony counts of potentially pathogenic bacteria were cultured from bronchoalveolar lavage (BAL) during diagnostic flexible fiberoptic bronchoscopy. STUDY DESIGN: This was a retrospective review of all medical records of children from infancy to 60 months of age seen in our specialty clinic from 1999 to 2009 with protracted cough, wheeze, and/or noisy breathing in whom BAL found ≥ 10(4) colony forming units per milliliter of potentially pathogenic bacteria. Children with other major diagnoses were excluded. RESULTS: With quantitative culture from BAL, ≥ 10(4) colony forming units per milliliter of Streptococcus pneumoniae, Haemophilus influenza, or Moraxella catarrhalis, separately or in combination, were found in 70 children. Neutrophilia was present in 87% of BALs. Tracheomalacia, bronchomalacia, or both was present in 52 children (74%). Symptoms were eliminated with antibiotics in all 61 children with follow-up data. Relapse and subsequent successful re-treatment occurred in 43 children. CONCLUSIONS: High colony counts of potentially pathogenic bacteria associated with neutrophilia in the BAL identifies protracted bacterial bronchitis. The predominance of airway malacia in these patients suggests an etiologic role for those airway anomalies. The potential for chronic airway damage from protracted bacterial bronchitis warrants further investigation.

Clinical patterns and natural history of asthma.

Childhood asthma typically begins in infancy with a respiratory syncytial virus (RSV) infection. Although the majority of infants become infected with RSV, lower respiratory illness develops in only about 20%. About 25% to 50% of those subsequently experience recurrent acute asthma from viral respiratory infections (VRI). Children younger than 5 years have a high frequency of VRI and have the highest frequency of hospitalization for asthma of any age group. In a 35-year study of the natural history of asthma, 20% of 7-year-old children were found to have asthma, but most had only episodic illness with VRI. The majority of those children improved with age, but a substantial minority continued to have recurrent episodes as adults, generally induced by VRI or exercise. Persistent asthma developed in only a few. Children who had symptoms of asthma without VRI were more likely to continue having frequent episodic or chronic asthma as adults. Despite generally suboptimal treatment during the 35 years of the study, forced expiratory volume at one second did not deteriorate over time; it remained normal in children who had only episodic asthma, and it was consistently low in the children with severe, persistent asthma.

Treatment strategies for viral respiratory infection-induced asthma.

The many therapeutic options for asthma can confuse both physicians and patients. Great emphasis has been placed on maintenance medication, particularly inhaled corticosteroids (ICS), which are the most effective medication for patients with persistent symptoms. However, asthma in young children is most commonly intermittent, triggered almost exclusively by viral respiratory infections (VRI). It is, nevertheless, associated with the highest rate of hospitalization of any age. Conventional doses of ICS do not prevent exacerbations of VRI-induced asthma. In contrast, intervention with oral corticosteroids during exacerbations has been shown to prevent the progression that would otherwise require urgent care or hospitalization. An oral corticosteroid kept on hand by the patient permits initiation of more prompt and effective treatment than is likely to occur when a patient must first go to a physician's office or emergency department, because it can be given as soon as the response to bronchodilator therapy is incomplete. Monitoring by phone and regularly scheduled physician visits to review the clinical course and reinforce education can then replace urgent medical care, thereby improving the quality and efficacy of asthma management.