Is there cardiac autonomic dysfunction in children and adolescents with exercise-induced bronchospasm?

BACKGROUND: The pulmonary impairment in patients with bronchoconstriction induced by eucapnic voluntary hyperpnea(EVH) goes beyond the respiratory system, also impairing autonomic nervous modulation. This study aimed to evaluate the behavior of cardiac autonomic modulation in young asthmatics with and without EIB after the EVH test. RESEARCH DESIGN AND METHODS: A cross-sectional study design using 54 asthmatics(51.9% female), aged between 10 and 19 years, investigated with the EVH test. Forced expiratory volume in one second(FEV1) was measured at 5, 10, 15, and 30 min after EVH. Heart rate variability(HRV) measures of time were assessed pre and 30 min-post EVH. The diagnosis of Exercise-Induced bronchoconstriction with underlying clinical asthma(EIBA) was confirmed by a fall in FEV1 ≥10% compared to baseline. RESULTS: Thirty(55.5%) asthmatics had EIBA. Subjects with EIBA have reduced mean of the R-R intervals in relation to baseline until 15 minutes after EVH. Individuals without EIBA had increased parasympathetic activity compared to baseline(rMSSD) from 5 min after EVH(p < 0.05). This parasympathetic activity increase in relation to baseline was seen in individuals with EIBA after 25 minutes (rMSSD = 49.9 ± 5.3 vs 63.5 ± 7.2, p < 0.05). CONCLUSION: Young asthmatics with EIBA present a delay in the increase of the parasympathetic component after EVH when compared to asthmatics without EIBA.

Can physical exercise assist in controlling and reducing the severity of exercise-induced bronchospasm in children and adolescents? A systematic review.

OBJECTIVE: The aim of this study was to analyze whether physical exercise can contribute to improving the control and severity of exercise-induced bronchospasm (EIB) in children and adolescents. METHOD: This is a systematic review that used PubMed/Medline and Scopus databases as a search source, and using descriptors indexed to DeCS/Mesh. The articles were analyzed in three stages in the selection process. Methodological quality was assessed using the TESTEX scale. RESULT AND DISCUSSION: A total of 5867 articles were filtered in the initial search; however, only eight of these were included after the eligibility criteria. All presented improvements in cardiorespiratory fitness. Only two followed the international EIB diagnostic guidelines. Of these, only one described a reduction in FEV1 and considered that this improvement may influence the EIB response in children and adolescent athletes with a non-asthmatic sample. CONCLUSION: The studies analyzed in this review did not enable drawing a conclusion regarding the influence of physical exercise on EIB in asthmatics. The lack of clinical trials on EIB and physical exercise, as well as the difficulty in methodological standardization for EIB diagnosis evidence the lack of scientific knowledge in this area, serving as a stimulus for researchers to find more consolidated answers.

Comparison between impulse oscillometry parameters and spirometry for the diagnosis of exercise-induced bronchoconstriction in asthmatic children and adolescents.

INTRODUCTION: Impulse oscillometry (IOS) parameters are obtained more easily and effortlessly in comparison to forced expiratory volume in the first second (FEV1). OBJECTIVE: To compare IOS parameters to FEV1 in exercise-induced bronchoconstriction (EIB) diagnosis. METHODS: Seventy-four (60.8% male; 39.2 female) young asthmatics aged between 7 and 17 years (mean 12.6 ± 2.8 years) were evaluated. EIB was defined as a reduction in FEV1 ≥ 10% compared with basal after standardized challenge by treadmill running (TR). IOS parameters and FEV1 were obtained at baseline and 5,15, and 30 min after TR. The area under the receiver operator characteristic curve (AUC) was calculated from the reduction in FEV1 ≥ 10% to evaluate the best psychometric characteristics of IOS parameters. RESULTS: Twenty-four individuals (32.4%) were diagnosed with EIB. A moderate inverse correlation was found between the IOS and FEV1 variables immediately after the TR, with resistance at 5 Hz (R5Hz), resonant frequency (Fres), and reactance area (AX), (r = -0.64, r = -0.53 and r = -0.69, respectively, all with p < 0.05). An increase of 25 kPa/l/s in R5 Hz, of 19k Pa/l/s in AX and 21 Hz in Fres were found to best correlate with EIB diagnosis by FEV1 (sensitivity 67% and specificity 62%, sensitivity 84% and specificity 50%, and sensitivity 84% and specificity 60%, respectively). CONCLUSION: IOS parameters have a significant inverse correlation with FEV1. This study presents cut-off points for EIB diagnosis for R5Hz, AX, and Fres, however, the findings in IOS parameters should be used and interpreted carefully if the goal is to replace spirometry.

Accuracy of peak nasal flow to determine nasal obstruction in patients with allergic rhinitis.

Objective: The aim of this study was to investigate the ability of Peak Nasal Inspiratory Flow (PNIF) and Peak Nasal Expiratory Flow (PNEF) measures to predict symptoms of nasal obstruction. Methods: This is a cross-sectional study, carried out in 131 individuals (64 with symptomatic allergic rhinitis and 67 asymptomatic) aged between 16 and 50 years. Results: PNIF and PNEF were higher among non-rhinitis. In the curve analysis (receiver operating characteristic), a value of 115 was found for PNIF with a sensitivity of 98.4% and specificity of 87.5% (AUC = 0.99, p < 0.001) and 165 in PNEF with a sensitivity of 65.7% and specificity of 85.1% (AUC = 0.92, p < 0.001). Conclusions: PNIF and PNEF values were lower in patients with AR compared to asymptomatic cases. Our findings present reference values of PNIF and PNEF in the evaluation of nasal obstruction symptoms and reinforce the importance to complement more refined assessment of patients' symptoms. PNEF can be a valuable tool in screening patients and to complement PNIF measurement.

Ventilation Rates Achieved in Eucapnic Voluntary Hyperpnea Challenge and Exercise-Induced Bronchoconstriction Diagnosis in Young Patients with Asthma.

PURPOSE: Exercise-induced bronchoconstriction (EIB) affects approximately 50% of young asthma patients, impairing their participation in sports and physical activities. Eucapnic voluntary hyperpnea (EVH) is an approved surrogate challenge to exercise for objective EIB diagnosis, but the required minimum target hyperventilation rates remain unexplored in this population. This study aimed to evaluate the association between the achieved ventilation rates (VRs) during a challenge and EIB-compatible response (EIB-cr) in young asthma patients. METHODS: This cross-sectional study included 72 asthma patients aged 10-20 years. Forced expiratory volume in the first second (FEV1) was measured before and 5, 15, and 30 min after the EVH. The target VR was set at 21 times the individual's baseline FEV1. A decrease of > 10% in FEV1 after the challenge was considered an EIB-cr. The challenge was repeated after 48-72 h in those without an EIB-cr. RESULTS: Thirty-six individuals had an EIB-cr at initial evaluation. The median VRs achieved was not different between individuals with and without an EIB-cr (19.8 versus 17.9; p = 0.619). The proportion of individuals with an EIB-cr was nor different comparing those who achieved (12/25) or not (24/47) the calculated target VRs (p = 0.804). At the repeated EVH challenge an EIB-cr was observed in 14/36 individuals with a negative response in the first evaluation, with no differences in achieved VRs between the two tests (p = 0.463). CONCLUSION: Irrespective of the achieved VR, an EIB-compatible response after an EVH challenge must be considered relevant for clinical and therapeutic judgment and negative tests should be repeated.

Lung mechanics and respiratory morbidities in school-age children born moderate-to-late preterm.

BACKGROUND: Late and moderate prematurity may have an impact on pulmonary function during childhood. The present study aimed to investigate lung mechanics in school-age children born moderate-to-late preterm (MLPT). METHODS: Children aged 5-10 years were enrolled in this case-control study. Lung function and bronchodilator response were assessed by impulse oscillometry (IOS) at two hospital-based specialized clinics. A structured questionnaire was employed to assess respiratory morbidities. RESULTS: A total of 123 children was divided into two groups: case (MLPT) n = 52 and control (children born at term) n = 71. The results showed no difference between groups in mean baseline IOS variables: R5 0.80 ± 0.20 vs 0.82 ± 0.22 kPa/L/s, p = 0.594, R20 0.54 ± 0.13 vs 0.55 ± 0.13 kPa/L/s, p = 0.732, R5-R20 0.26 ± 0.12 vs 0.27 ± 0.15 kPa/L/s, p = 0.615, X5 -0.29 ± 0.01 vs -0.29 ± 0.1 kPa/L/s, p = 0.990, Fres 21.1 ± 3.3 vs 21.7 ± 3.1 L/s, p = 0.380, and AX 2.7 ± 3.36 vs 2.5 ± 1.31 kPa/L/s, p = 0.626. Bronchodilator response and the occurrence of respiratory morbidities after birth were also similar between groups. CONCLUSIONS: This study found lung mechanics parameters to be similar in school-age children born MLPT and those born at term, suggesting that pulmonary plasticity continues to occur in children up to school age. IMPACT: Late and moderate prematurity is associated with an increased risk of reduced pulmonary function during childhood. Follow-up reports in adolescents and adults born MLPT are scarce but have indicated pulmonary plasticity with normalization of airway function. Our results show that the lung function in school-age children born MLPT is similar to that of children born at term.

Respiratory burden in obese and young asthmatics: a study of diaphragmatic kinetics. / Carga respiratória em obesos e jovens asmáticos: um estudo da cinética diafragmática.

OBJECTIVE: The aim of this study was to assess the diaphragm kinetics, respiratory function, and serum dosage of leptin and inflammatory cytokines (IL-6 and TNF-α) in three clinical groups: obese, asthmatic, and healthy. METHODS: This is a clinical exploratory study performed on 73 youths (12-24 years of age, 42.5% male) allocated into three groups: obesity (OG, n=33), body mass index (BMIz-score) ≥ +2, asthmatic (AG, n=26) controlled mild asthmatics, classified by GINA, and Healthy Control Group (CG, n=14). The participants were subjected to diaphragmatic ultrasound, spirometry, maximal respiratory pressure, serum leptin levels, and IL-6 and TNF-α whole blood cell culture levels. RESULTS: Diaphragm thickness was higher in OG in comparison to AG and CG (2.0±0.4 vs 1.7±0.5 and 1.6±0.2, both with p<0.05). Maximal voluntary ventilation (MVV) was significantly lower in OG and AG in relation to the CG (82.8±21.4 and 72.5±21.2 vs 102.8±27.3, both with p<0.05). OG has the highest leptin rate among the groups (with the other two groups had p<0.05). All groups had similar TNF-α and IL-6 levels. CONCLUSION: The muscular hypertrophy found in the diaphragm of the obese individuals can be justified by the increase in respiratory work imposed by the chronic condition of the disease. Such increase in thickness did not occur in controlled mild asthmatics. The IL-6 and TNF-α markers detected no evidence of muscle inflammation, even though leptin was expected to be altered in obese individuals. Both obese and asthmatic patients had lower pulmonary resistance than the healthy ones.

OBJETIVO: O objetivo deste estudo foi avaliar a cinética diafragmática, a função respiratória e a dosagem sérica de leptina e citocinas inflamatórias (IL-6 e TNF-α) em três grupos clínicos: obeso, asmático e saudável. MÉTODOS: Estudo clínico-exploratório realizado com 73 jovens (12-24 anos, sendo 42,5% do sexo masculino) alocados em três grupos: obesidade (GO, n = 33), índice de massa corporal (IMC z-score) ≥ + 2 e asmáticos leves controlados (GA, n = 26), classificados pela GINA, e grupo controle saudável (GC, n = 14). Os participantes foram submetidos à ultrassonografia diafragmática, espirometria, pressão respiratória máxima, níveis séricos de leptina e níveis de IL-6 e TNF-α em hemocultura total. RESULTADOS: A espessura do diafragma foi maior no GO em comparação ao GA e GC (2,0 ± 0,4 vs 1,7 ± 0,5 e 1,6 ± 0,2, respectivamente, com p < 0,05). A ventilação voluntária máxima (VVM) foi significativamente menor no GO e GA em relação ao GC (82,8 ± 21,4 e 72,5 ± 21,2 vs 102,8 ± 27,3, respectivamente, com p < 0,05). O GO tem a maior taxa de leptina entre todos os grupos (com os outros dois grupos, p < 0,05). Os três grupos tinham níveis semelhantes de TNF-α e IL-6. CONCLUSÃO: A hipertrofia muscular encontrada no diafragma de indivíduos obesos pode ser justificada pelo aumento do trabalho respiratório imposto pela condição crônica da doença. Esse aumento de espessura não ocorreu em asmáticos leves controlados. Os marcadores IL-6 e TNF-α não detectaram evidências de inflamação muscular, embora fosse esperado que a leptina estivesse alterada em indivíduos obesos. Pacientes obesos e asmáticos apresentaram menor resistência pulmonar do que os saudáveis.

Reproducibility of eucapnic voluntary hyperpnoea for exercise-induced bronchoconstriction diagnosis in asthmatic children and adolescents.

BACKGROUND: Respiratory symptoms after exercise are frequently reported by asthmatic patients, and exercise-induced bronchoconstriction (EIB) is a frequent cause, which requires objective testing for diagnosis. Eucapnic voluntary hyperpnea (EVH) is recommended as a surrogate stimulus for this purpose. Its short-term reproducibility is not yet established in children and young adolescents with asthma. OBJECTIVE: To evaluate the short-term test-retest agreement and reproducibility of FEV1 changes after EVH in this population. METHODS: Asthmatic patients aged between 10 and 20 years underwent EVH for EIB diagnosis on two occasions 2-4 days apart at a specialized university clinic. FEV1 was measured at 5, 15, and 30 min after EVH with a target ventilation rate 21 times the baseline FEV1 . EIB was diagnosed as a decrease ≥10% in FEV1 from baseline. RESULTS: A total of 26 of 62 recruited individuals tested positive for EIB on both visits (positive group) and 17 on one visit only (divergent group), while 19 tested negative on both visits (negative group). The overall agreement was 72.5% (95%CI 61.6%, 83.6%), and Cohen's kappa coefficient was 0.452. Low bias (0.87%) and high intra-class correlation coefficient (0.854, 95%CI 0.758,0.912; p < .001) for FEV1 response between test days were found, but with wide limits of agreement (±20.72%). There were no differences in pre-challenge FEV1 or achieved ventilation rate between visits either between groups (p = .097 and p = .461) or within groups (p = .828 and p = .780). There were no safety issues. CONCLUSIONS: More than one EVH test should be performed in children and young adolescents with asthma to exclude EIB and minimize misdiagnosis and mistreatment.

An expert review on breaking barriers in severe asthma in Brazil: Time to act.

Currently, Brazil lacks a national asthma management program and is burdened with nearly 200,000 hospitalizations due to the disease per year and approximately 5 deaths per day. The purpose of this article was to analyze the current issues surrounding severe asthma in Brazil, as the status of diagnosis and treatment is largely unknown, and to provide feasible recommendations to elicit imminent action. A panel of Brazilian medical experts in the field of severe asthma was provided with a series of relevant questions to address prior to a multi-day conference. Within this conference, each narrative was discussed and edited by the entire group. Through numerous rounds of discussion consensus was achieved. In order to overcome barriers to adequate asthma treatment, this panel recommends specific initiatives that can be implemented in the short-term to decrease the burden of severe asthma in Brazil. With increasing healthcare costs and limited resources globally, there is an opportunity to implement these recommendations in other countries in order to achieve adequate asthma care. Severe asthma is a heterogeneous and complex disease with various phenotypes that requires strict attention for diagnosis and management. Although this disease affects only a small proportion of the population with asthma, it poses a great burden to healthcare systems. Thus, barriers to diagnosis, treatment, and management should be overcome as quickly and efficiently as possible.

New Oxazolidines Inhibit the Secretion of IFN-γ and IL-17 by PBMCS from Moderate to Severe Asthmatic Patients.

BACKGROUND: Moderate to severe asthma could be induced by diverse proinflammatory cytokines, as IL-17 and IFN-γ, which are also related to treatment resistance and airway hyperresponsiveness. Oxazolidines emerged as a novel approach for asthma treatment, since some chemical peculiarities were suggested by previous studies. OBJECTIVE: The present study aimed to evaluate the IL-17A and IFN-γ modulatory effect of two new oxazolidine derivatives (LPSF/NB-12 and -13) on mononucleated cells of patients with moderate and severe asthma. METHODS: The study first looked at potential targets for oxazolidine derivatives using SWISS-ADME. After the synthesis of the compounds, cytotoxicity and cytokine levels were analyzed. RESULTS: We demonstrated that LPSF/NB-12 and -13 reduced IFN-γ and IL-17 production in peripheral blood mononucleated cells from asthmatic patients in a concentrated manner. Our in silico analysis showed the neurokinin-1 receptor as a common target for both compounds, which is responsible for diverse proinflammatory effects of moderate and severe asthma. CONCLUSION: The work demonstrated a novel approach against asthma, which deserves further studies of its mechanisms of action.

Carga respiratória em obesos e jovens asmáticos: um estudo da cinética diafragmática / Respiratory burden in obese and young asthmatics: a study of diaphragmatic kinetics

RESUMO Objetivo O objetivo deste estudo foi avaliar a cinética diafragmática, a função respiratória e a dosagem sérica de leptina e citocinas inflamatórias (IL-6 e TNF-α) em três grupos clínicos: obeso, asmático e saudável. Métodos Estudo clínico-exploratório realizado com 73 jovens (12-24 anos, sendo 42,5% do sexo masculino) alocados em três grupos: obesidade (GO, n = 33), índice de massa corporal (IMC z-score) ≥ + 2 e asmáticos leves controlados (GA, n = 26), classificados pela GINA, e grupo controle saudável (GC, n = 14). Os participantes foram submetidos à ultrassonografia diafragmática, espirometria, pressão respiratória máxima, níveis séricos de leptina e níveis de IL-6 e TNF-α em hemocultura total. Resultados A espessura do diafragma foi maior no GO em comparação ao GA e GC (2,0 ± 0,4 vs 1,7 ± 0,5 e 1,6 ± 0,2, respectivamente, com p < 0,05). A ventilação voluntária máxima (VVM) foi significativamente menor no GO e GA em relação ao GC (82,8 ± 21,4 e 72,5 ± 21,2 vs 102,8 ± 27,3, respectivamente, com p < 0,05). O GO tem a maior taxa de leptina entre todos os grupos (com os outros dois grupos, p < 0,05). Os três grupos tinham níveis semelhantes de TNF-α e IL-6. Conclusão A hipertrofia muscular encontrada no diafragma de indivíduos obesos pode ser justificada pelo aumento do trabalho respiratório imposto pela condição crônica da doença. Esse aumento de espessura não ocorreu em asmáticos leves controlados. Os marcadores IL-6 e TNF-α não detectaram evidências de inflamação muscular, embora fosse esperado que a leptina estivesse alterada em indivíduos obesos. Pacientes obesos e asmáticos apresentaram menor resistência pulmonar do que os saudáveis.

ABSTRACT Objective The aim of this study was to assess the diaphragm kinetics, respiratory function, and serum dosage of leptin and inflammatory cytokines (IL-6 and TNF-α) in three clinical groups: obese, asthmatic, and healthy. Methods This is a clinical exploratory study performed on 73 youths (12-24 years of age, 42.5% male) allocated into three groups: obesity (OG, n=33), body mass index (BMIz-score) ≥ +2, asthmatic (AG, n=26) controlled mild asthmatics, classified by GINA, and Healthy Control Group (CG, n=14). The participants were subjected to diaphragmatic ultrasound, spirometry, maximal respiratory pressure, serum leptin levels, and IL-6 and TNF-α whole blood cell culture levels. Results Diaphragm thickness was higher in OG in comparison to AG and CG (2.0±0.4 vs 1.7±0.5 and 1.6±0.2, both with p<0.05). Maximal voluntary ventilation (MVV) was significantly lower in OG and AG in relation to the CG (82.8±21.4 and 72.5±21.2 vs 102.8±27.3, both with p<0.05). OG has the highest leptin rate among the groups (with the other two groups had p<0.05). All groups had similar TNF-α and IL-6 levels. Conclusion The muscular hypertrophy found in the diaphragm of the obese individuals can be justified by the increase in respiratory work imposed by the chronic condition of the disease. Such increase in thickness did not occur in controlled mild asthmatics. The IL-6 and TNF-α markers detected no evidence of muscle inflammation, even though leptin was expected to be altered in obese individuals. Both obese and asthmatic patients had lower pulmonary resistance than the healthy ones.

Impulse oscillometry: pulmonary function assessment in preschool children.

OBJECTIVES: In contrast to spirometry, which requires active participation of the individual and is challenging for the preschool age group, the impulse oscillometry system comprises a test that minimizes the degree of coordination required. The study aimed to compare the results of Impulse Oscillometry System (IOS) in children with and without respiratory symptoms. METHODS: A cross-sectional study was conducted in children aged between 3 and 6 years. A short version of the ATS-DLD-78-C questionnaire validated for Brazilian children was applied to identify two groups: children with and without respiratory symptoms. The IOS analysis was carried out measuring the following parameters in triplicate: resistance at 5 Hz (R5Hz) and 20 Hz (R20Hz), respiratory reactance at 5 Hz (X5Hz), and R5-R20Hz before and after bronchodilator application. RESULTS: A total of 76 preschoolers were selected, 55 (72.4%) of whom had respiratory complaints. The coefficient of variability of R5Hz was ≤17% in 70/76 (92.1%) of the children. Resistances at R5Hz and R5-R20Hz in the children with respiratory complaints reached values higher than those of children without symptoms before bronchodilation. CONCLUSIONS: The results obtained for resistance using IOS in children with respiratory symptoms were higher in the pre-bronchodilator examination for R5Hz and R5-R20Hz compared to those of children without respiratory symptoms. EXPERT OPINION: Prospective investigations suggest that irreversible changes in lung function begin in infancy, before reaching school age. Pulmonary function follow-up in children with recurrent wheezing or asthma is important for confirmation of diagnosis and evaluation of the disease severity. The Impulse Oscillometry System (IOS) can be useful in assessing children's pulmonary function since it requires minimal patient cooperation and can be successfully applied to preschool children being an alternative to individuals who have difficulty performing spirometry.

2020 Brazilian Thoracic Association recommendations for the management of asthma.

The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages.

Impact of moderate-severe persistent allergic rhinitis on thoraco-abdominal kinematics and respiratory muscle function.

Objective: To assess thoraco-abdominal kinematics, respiratory muscle strength and electromyographic activity of the diaphragm (EAdi) in moderate-severe allergic rhinitis (AR) patients. Methods: A cross-sectional study involving 40 individuals (20 in the AR group) and 20 in the control group [CG]) was conducted. Ventilatory pattern and chest wall volume distribution (optoelectronic plethysmography), respiratory muscle strength (manovacuometry and sniff nasal inspiratory pressure [SNIP]), and EAdi were assessed in both groups. Results: The AR patients had impaired thoraco-abdominal kinematics (reduced total chest wall volume) (p = 0.004), lower values of total respiratory cycle time (p = 0.014) and expiratory time (p = 0.006). They also presented an increase of percentage contribution of the abdominal rib cage (p = 0.475) and respiratory rate (p = 0.019). A positive correlation among pulmonary rib cage tidal volume and MIP (r = 0.544; p < 0.001), SNIP (r = 0.615; p < 0.001), and MEP (r = 0.604; p < 0.001) was observed. After adjusting for age, BMI and gender through multivariate analysis, the individuals with AR presented lower values ​​of MIP (ß = -24.341; p < 0.001), MEP (ß = -0.277; p < 0.001), SNIP (ß = -34.687; p < 0.001) and RMS (ß = -0.041; p = 0.017). Conclusions: The individuals with moderate-severe persistent AR had worse respiratory muscle strength, diaphragm activation and chest wall volume distribution with a higher abdominal contribution to tidal volume than the control group. These findings reinforce the notion that the upper and lower airways work in an integrated and synergistic manner.

2020 Brazilian Thoracic Association recommendations for the management of asthma / Recomendações para o manejo da asma da Sociedade Brasileira de Pneumologia e Tisiologia - 2020

ABSTRACT The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages.

RESUMO O manejo farmacológico da asma mudou consideravelmente nas últimas décadas, com base no entendimento de que a asma é uma doença heterogênea e complexa, com diferentes fenótipos e endótipos. Agora está claro que o objetivo do tratamento da asma deve ser alcançar e manter o controle da doença e evitar riscos futuros (exacerbações, instabilidade da doença, perda acelerada da função pulmonar e efeitos adversos do tratamento). Isso implica em uma abordagem personalizada, incluindo tratamento farmacológico, educação do paciente, plano de ação por escrito, treinamento para uso do dispositivo inalatório e revisão da técnica inalatória a cada visita ao consultório. Um painel de 22 pneumologistas brasileiros foi convidado a revisar criticamente evidências recentes de tratamento farmacológico da asma e a preparar esta recomendação, um guia de tratamento adaptado à nossa realidade. A escolha dos tópicos ou questões relacionadas às mudanças mais significativas nos conceitos e, consequentemente, no manejo da asma na prática clínica foi realizada por um painel de especialistas. Foi solicitado a cada especialista que revisasse criticamente um tópico ou respondesse a uma pergunta, com base em evidências, para estas recomendações. Numa segunda fase, três especialistas discutiram e estruturaram todos os textos submetidos pelos demais e, na última fase, todos revisaram e discutiram cada recomendação. As presentes recomendações se aplicam a adultos e crianças com asma e destinam-se a médicos envolvidos no tratamento da doença.

Guia para o manejo da asma grave 2019 ­ Associação Brasileira de Alergia e Imunologia / Guide to the management of severe asthma 2019 ­ Brazilian Association of Allergy and Immunology

Antes de rotular um paciente como tendo asma grave, é crucial confirmar o diagnóstico da doença e de sua gravidade, além de excluir diagnósticos diferenciais de condições que podem se assemelhar ou se confundir com a asma, tais como: tuberculose, doença pulmonar obstrutiva crônica, disfunção de corda vocal, apneia do sono, bronquiectasia, entre outras. Neste guia são abordados, além dos diagnósticos diferenciais, dados de história clínica e exames laboratoriais que permitem classificar o paciente com relação à evolução da doença (controlado ou não controlado) e, assim, possibilitar a instituição do esquema terapêutico mais apropriado. São apresentadas alternativas terapêuticas disponíveis para a abordagem clínica desses pacientes, incluindo os imunobiológicos.

Prior to labeling a patient as having severe asthma, a crucial step is to confirm the diagnosis and severity as well as to exclude conditions that may resemble or be mistaken for asthma such as tuberculosis, chronic obstructive pulmonary disease, vocal cord dysfunction, sleep apnea, bronchiectasis, among others. In addition to differential diagnoses, this guide addresses clinical history data and laboratory tests that classify the patient regarding disease progression (controlled or uncontrolled asthma), allowing the establishment of an adequate therapeutic plan. Therapeutic options available for the treatment of these patients are detailed, including biologics.

Physical activity level in asthmatic adolescents: cross-sectional population-based study / Nível de atividade física em adolescentes asmáticos: estudo transversal comparativo de base populacional

ABSTRACT Objective: To assess the level of physical activity in asthmatics in comparison with non-asthmatics in a population study. Methods: Cross-sectional study with 13 to 14-year-old adolescents who participated in the International Study of Asthma and Allergies in Childhood (ISAAC). The subjects were classified into three groups: individuals with active asthma, individuals diagnosed with asthma, and respiratory asymptomatic individuals. To evaluate the level of physical activity, the International Physical Activity Questionnaire (IPAQ-short version) was used. The analysis consisted of comparing individuals with active asthma, diagnosed as asthmatic and asymptomatic, with a significance level of 5%. Results: The participants were 1,591 adolescents, of which 791 (49.7%) were male. There were 222 (14.0%) individuals with active asthma and 284 (17.8%) asthma diagnoses; 55% of the population were physically active. Adolescents diagnosed with asthma were more active than their non-asthmatic peers (64.4 versus 53.3%; p=0.001). Conclusions: Adolescents diagnosed with asthma were more physically active than their non-asthmatic peers.

RESUMO Objetivo: Avaliar o nível de atividade física (AF) em asmáticos, comparando com não asmáticos, em estudo populacional. Métodos: Estudo transversal com adolescentes de 13 a 14 anos que participaram do estudo International Study of Asthma and Allergies in Childhood (ISAAC). Os indivíduos foram classificados em três grupos: indivíduos com asma ativa, indivíduos com diagnóstico de asma e assintomáticos respiratórios. Para avaliar o nível de AF, foi utilizado o Questionário Internacional de Atividade Física (IPAQ) versão curta. A análise consistiu na comparação de indivíduos com asma ativa, com diagnóstico de asma e assintomáticos, sendo o nível de significância considerado de 5%. Resultados: Participaram da pesquisa 1.591 adolescentes, 791 (49,7%) do sexo masculino. Apresentaram asma ativa 222 (14,0%) indivíduos e diagnóstico de asma 284 (17,8%). Foram fisicamente ativos 55,1% da população. Adolescentes com diagnóstico de asma foram mais ativos do que seus pares não asmáticos (64,4 versus 53,3%; p=0,001). Conclusões: Adolescentes com diagnóstico de asma apresentavam-se fisicamente mais ativos do que seus pares não asmáticos.

PHYSICAL ACTIVITY LEVEL IN ASTHMATIC ADOLESCENTS: CROSS-SECTIONAL POPULATION-BASED STUDY.

OBJECTIVE: To assess the level of physical activity in asthmatics in comparison with non-asthmatics in a population study. METHODS: Cross-sectional study with 13 to 14-year-old adolescents who participated in the International Study of Asthma and Allergies in Childhood (ISAAC). The subjects were classified into three groups: individuals with active asthma, individuals diagnosed with asthma, and respiratory asymptomatic individuals. To evaluate the level of physical activity, the International Physical Activity Questionnaire (IPAQ-short version) was used. The analysis consisted of comparing individuals with active asthma, diagnosed as asthmatic and asymptomatic, with a significance level of 5%. RESULTS: The participants were 1,591 adolescents, of which 791 (49.7%) were male. There were 222 (14.0%) individuals with active asthma and 284 (17.8%) asthma diagnoses; 55% of the population were physically active. Adolescents diagnosed with asthma were more active than their non-asthmatic peers (64.4 versus 53.3%; p=0.001). CONCLUSIONS: Adolescents diagnosed with asthma were more physically active than their non-asthmatic peers.