Asma inducida por ejercicio / Exercise­induced asthma

El asma es una enfermedad crónica que se caracteriza por la presencia de inflamación de las vías aéreas, que puede ser reversible. El ejercicio físico puede ser uno de los factores que pueden desencadenar síntomas en pacientes con o sin diagnóstico de asma bronquial. Actualmente hay dos hipótesis (térmica y osmótica) que justifican la causa del asma inducida por ejercicio (AIE). El diagnóstico de AIE se establece por cambios en la función pulmonar provocados por el ejercicio, y no en función de los síntomas. Existen diversas medidas farmacológicas y no farmacológicas destinadas al tratamiento de AIE. El entrenamiento físico es beneficioso tanto en niños como en adultos con asma. (AU)

The KAAACI Standardization Committee Report on the procedure and application of the bronchial provocation tests

Bronchial provocation tests are of value in the evaluation of airway hyperresponsiveness. Nonspecific bronchial challenge (methacholine, mannitol, exercise, etc.) is used when the symptoms, physical examination, and measurements of pulmonary function are unremarkable in the diagnosis of asthma, when a patient is suspected of having occupational asthma or exercise-induced bronchoconstriction (EIB), and when a screening test for asthma or EIB is required for some occupational groups in whom bronchospasm would pose an unacceptable hazard. Methacholine inhalation challenge is most widely used pharmacologic challenge and highly sensitive. For appropriate interpretation of the results of methacholine provocation, it is important to perform the test with the standardized protocol and to recognize that inhalation methods significantly influence the sensitivity of the procedure. Indirect challenges (e.g., mannitol and exercise) correlate with airway inflammation and are more specific but less sensitive for asthma. Indirect provocation tests are used to confirm asthma, to differentiate asthma from other airway diseases, and to evaluate EIB.

Usefulness of serum lactate as a predictor of successful discontinuation of continuous atropine infusion in patients with severe acute organophosphate poisoning

OBJECTIVE: In severe organophosphate (OP) poisoning, administration of atropine via continuous intravenous infusion is typically considered. To date, there have been no studies on predicting successful atropine discontinuation through plasma cholinesterase (PChE) and serum lactate levels, which are monitored during critical care in severe acute OP poisoning. Therefore, we retrospectively evaluated the usefulness of serum lactate and PChE as predictors of successful discontinuation of atropine infusion. METHODS: This retrospective observational study was performed on consecutive adult patients treated for severe acute OP poisoning between March 2011 and December 2016. We sequentially evaluated serum lactate and PChE levels on emergency department arrival and before a discontinuation trial of atropine infusion. Discontinuation of atropine intravenous infusion was attempted in patients after clearance of respiratory secretions and cessation of bronchoconstriction. Discontinuation of atropine infusion attempts were divided into successful and failed trials. RESULTS: A total of 95 trials were conducted in 62 patients. Serum lactate levels before trials were significantly different between patients with successful and failed trials. The area under the curve for prediction of successful atropine discontinuation using serum lactate levels before trial discontinuation were 0.742 (95% confidence interval, 0.638 to 0.846). PChE level was not significantly different between two groups. CONCLUSION: Serum lactate levels before the discontinuation trial of atropine infusion served to predict successful discontinuation in severe acute OP poisoning.

Respiratory Function and Symptoms Post Cold Air Exercise in Female High and Low Ventilation Sport Athletes

PURPOSE: Cold weather exercise is common in many regions of the world; however, it is unclear whether respiratory function and symptom worsen progressively with colder air temperatures. Furthermore, it is unclear whether high-ventilation sport background exacerbates dysfunction and symptoms. METHODS: Seventeen active females (measure of the maximum volume of oxygen [VO(2max)]: 49.6±6.6 mL·kg⁻¹·min⁻¹) completed on different days in random order 5 blinded running trials at 0℃, -5℃, -10℃, -15℃, and -20℃ (humidity 40%) in an environmental chamber. Distance, heart rate, and rating of perceived exertion (RPE) were measured within each trial; forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), forced expiratory flow at 25%-75% (FEF₂₅₋₇₅), and forced expiratory flow at 50% (FEF₅₀) were measured pre- and post-test (3, 6, 10, 15, and 20 minutes). Respiratory symptoms and global effort were measured post-test spirometry. RESULTS: Mean decreases were found in FEV1 (4%-5% at 0℃, -5℃, -10℃, and -15℃; 7% at -20℃). FEF₂₅₋₇₅ and FEF₅₀ decreased 7% and 11% at -15℃ and -20℃, respectively. Post-exertion spirometry results were decreased most at 3 to 6 minutes, recovering back to baseline at 20 minutes. Respiratory symptoms and global effort significantly increased at -15℃ and -20℃ with decreased heart rate. High-ventilation sports decreased function more than low-ventilation participants but had fewer symptoms. CONCLUSIONS: These results indicate that intense exercise at cold air temperatures up to -20℃ is achievable; however, greater effort along with transient acute bronchoconstriction and symptoms of cough after exercising in temperatures colder than -15℃ are likely. It is recommended that individuals cover their mouth and reduce exercise intensity to ameliorate the effects of cold weather exercise.

Dyspnea Perception During Induced Bronchoconstriction Is Complicated by the Inhaled Methacholine in Children With Clinical Asthma

PURPOSE: Dyspnea is not widely utilized as an indicator of asthma provocation despite its universal presentation. We hypothesized that dyspnea severity was proportionate with the lung function decline, methacholine dose-step, and the degree of bronchial hyperresponsiveness (BHR). METHODS: We retrospectively analyzed 73 children's bronchial provocation test data with an assessment of dyspnea at every dose-step. Dyspnea severity was scored using a modified Borg (mBorg) scale. A linear mixed effect analysis was performed to evaluate the relationship between the mBorg scale, the percentage fall in the forced expiratory volume in 1 second (FEV1) (ΔFEV1%), the methacholine dose-step, and the degree of BHR (BHR grade). RESULTS: Subjects were divided into 5 BHR groups based on their last methacholine dose-steps. The mBorg scores did not differ significantly among BHR groups (P=0.596, Kruskal-Wallis test). The linear mixed effect analysis showed that ΔFEV1% was affected by the methacholine dose-step (P < 0.001) and BHR grade (P < 0.001). The mBorg score was affected by the dose-step (P < 0.001) and BHR grade (P=0.019). We developed a model to predict the mBorg score and found that it was affected by the methacholine dose-step and ΔFEV1%, elevating it by a score of 0.039 (χ² [1]=21.06, P < 0.001) and 0.327 (χ² [1]=47.45, P < 0.001), respectively. A significant interaction was observed between the methacholine dose-step and ΔFEV1% (χ² [1]=16.20, P < 0.001). CONCLUSIONS: In asthmatic children, inhaled methacholine, as well as the degree of BHR and lung function decline, may affect dyspnea perception during the bronchial provocation test. If we wish to draw meaningful information from dyspnea perception, we have to consider various complicating factors underlying it.

Comparison on the profiles of a modified Borg scale and the pediatric dyspnea scale during an induced bronchoconstriction in children with clinical asthma

PURPOSE: Dyspnea is the cardinal symptom of asthma, but it is difficult to quantify clinically. Although modified Borg (mBorg) scale has been successfully used in adult, but there has been some difficulties to apply in children. Recently, Pediatric Dyspnea Scale (PDS) was adequately designed and has been widely used. The aim of this study is to compare 2 evaluating scales of dyspnea provoked by induced-bronchoconstriction in childhood asthma. METHODS: Seventy-three clinically suspected children with asthma were enrolled in this study. Each ‘fractional exhaled nitric oxide (FeNO)’ was documented. Forced expiratory volume in 1 second (FEV₁), mBorg score and PDS score were recorded during methacholine provocation test. RESULTS: Mapping using canonical plot demonstrated global similarity between 2 scales with some distinctive features. Whereas mBorg score showed more diverse categories in low level of dyspnea, PDS score did in medium level of it. A distribution of dyspnea perception score at a 20% decrease in FEV₁ relative to baseline (PS₂₀), a perception score of dyspnea at 20% fall in FEV1 of 2 scales represented similar wide, biphasic feature. Statistical relevance was verified with spearman correlation (R(s)=0.903, P<0.001) and Bland-Altman analysis. PS₂₀ of both scores and FeNO had no statistical relationship. While relationship between PS20 by mBorg score and the concentration of methacholine at 20% fall in FEV₁ (PC₂₀) was not significant (R(s)=0.224, P=0.154), that between PS₂₀ by PDS and PC₂₀ was weak positive (R(s)=0.29, P=0.063). CONCLUSION: PDS had similar pattern to assess the dyspnea with the mBorg scale suggesting adequacy of PDS in evaluating pediatric clinical asthma. We expect these scales to help clinical practice in complementary ways.

Is Performance of a Modified Eucapnic Voluntary Hyperpnea Test in High Ventilation Athletes Reproducible?

PURPOSE: Exercise-induced bronchoconstriction (EIB) is common in “high ventilation” athletes, and the Eucapnic Voluntary Hyperpnea (EVH) airway provocation test is the standard EIB screen. Although the EVH test is widely used, the in-test performance in high ventilation athletes as well as the reproducibility of that performance has not been determined. Reproducibility of pre- and post-test spirometry and self-reported atopy/cough was also examined. METHODS: High ventilation athletes (competitive swimmers; n=11, 5 males) completed an atopy/cough questionnaire and EVH testing (operator controlled FiCO₂) on 2 consecutive days. RESULTS: Swimmers achieved 85%±9% and 87%±9% of target FEV1 volume on days 1 and 2, respectively, (P=0.45; ICC 0.57 [0.00-0.86]) resulting in a total ventilation of 687 vs 684 L [P=0.89, ICC 0.89 (0.65-0.97]) equating to 83%±8% and 84%±9% of predicted total volume (ICC 0.54 [0.00-0.85]) between days 1 and 2. FiCO₂ required to maintain eucapnic conditions was 2.5%. Pre-test FEV1 was less on day 2 (P=0.04; ICC >0.90). Day 1 to 2 post-test FEV1 was not different, and 4 swimmers were EIB positive (>10% fall in pre-post FEV1) on day 1 (3 on day 2). CONCLUSIONS: EVH in-test performance is reproducible however required less FiCO₂ than standard protocol and the swimmers under-ventilated by 125 and 139 L/min for days 1 and 2, respectively. How this affects EIB diagnosis remains to be determined; however, our results indicate a post-test FEV1 fall of ≥20% may be recommended as the most consistent diagnostic criterion.

Reversion of methacholine induced bronchoconstriction with inhaled diazepam in patients with asthma / Bloqueo de la respuesta bronco constrictora a metacolina con diazepam inhalado en pacientes con asma

Background: Benzodiazepines have a direct bronchodilatory effect. Methacholine is a non-selective muscarinic receptor agonist causing bronchoconstriction. Aim: To examine the effects of inhaled benzodiazepines, modulating bronchoconstriction induced by methacholine in patients with asthma. Patients and Methods: Twelve patients with well controlled asthma were studied. On the first day, after determining the initial values of pulmonary function, a dose response curve was carried out with progressive doses of methacholine. After the last dose, when at least a 20% drop of the initial forced expiratory volume in the first second (FEV1) was achieved, vital capacity (VC) and FEV1 were measured at 7, 15 and 30 minutes after provocation. On the second day a diazepam aerosol was inhaled by the patients prior to the same protocol with methacholine. Results: In the first day of testing, methacholine inhalation (6 mg/mL) led to a significant drop in FEV1 from 2.98 to 1.69 L. On the second day of study, in the same patients, previous inhalation with diazepam reduced the changes of FEV1 after inhalation of methacholine. This parameter decreased from 2.48 to 2.21 L. Conclusions: Inhalation of benzodiazepines reduce bronchoconstriction after a methacholine challenge in patients with asthma.

Antecedentes: Las benzodiacepinas tienen un efecto broncodilatador directo. La metacolina es un agonista muscarínico que causa bronco constricción. Objetivo: Evaluar el efecto modulador de la inhalación de diazepam sobre la bronco constricción inducida por metacolina. Pacientes y Métodos: Se estudiaron 12 pacientes con asma bien controlada. En el primer día, se determinó la curva dosis respuesta de parámetros de función pulmonar a una dosis progresiva de metacolina. Después de la última dosis, cuando se consiguió un 20% de reducción en la capacidad vital forzada en el primer segundo (FEV1), se midió FEV1 y la capacidad vital (CV) a los 7, 15 y 30 min después de la provocación. En el segundo día los pacientes se inhalaron con diazepam antes de hacer la prueba con metacolina. Resultados: En el primer día, el FEV1 bajo de 2,98 a 1,69 l con 6 mg/ml de metacolina. En el segundo día, la inhalación de diazepam redujo la respuesta a metacolina con una reducción de FEV1 de 2,48 a 2,21 L. Conclusiones: La benzodiacepinas reducen la respuesta de vasoconstricción a metacolina.

Propranolol as a First-line Treatment for Pediatric Hemangioma: Outcome of a Single Institution Over One Year / 임상소아혈액종양

BACKGROUND: Propranolol, a beta-blocker and well known anti-hypertensive medication, has been used as the first-line therapy for pediatric hemangioma since 2010. The objective of this study is to analyze the efficacy and safety of propranolol when used to treat pediatric hemangioma patients for one year or longer in a single institution.METHODS: A retrospective chart review analysis was done of 65 pediatric hemangioma patients treated with oral propranolol as the first-line therapy from 2010 to 2016. The patients were examined regularly at an interval of 1 to 2 months for changes in hemangioma size, growth and development, and occurrence of acute side effects of propranolol such as hypotension, hypoglycemia and bronchial constriction.RESULTS: Twenty patients were treated with propranolol for a year or longer and their median age was 202 days (range, 36 to 4,284 days) and mean duration of treatment was 22.5 months (range, 12 to 49 months). At 12 months of treatment, the average percentage of size decrement was 40.5%. When the weight and height percentile were compared between at diagnosis and 12 months post-treatment, all 20 patients showed normal growth curve and development. Patients did not show any acute side effects of propranolol during 12 months of treatment. One patient experienced hypoglycemia induced seizure, but this event was subsequently diagnosed as ketotic hypoglycemia induced from prolonged fasting.CONCLUSION: Propranolol was effective and well tolerated in children with hemangioma when used for one year or longer.

A Case of Diffuse Neonatal Hemangiomatosis Successfully Treated with Propranolol / 임상소아혈액종양

We present a case of a 41-day-old girl with diffuse hemangiomatosis on her chin, right thigh, occipital area, and liver. She also had hepatomegaly, heart failure, and hypothyroidism. Hemangiomatosis did not respond to 2 weeks of oral administration of prednisolone, but was successfully treated with propranolol. After 2 years of propranolol treatment, the lesions of hemangiomatosis nearly disappeared. Hypothyroidism was controlled by levothyroxine replacement. As hemangiomatosis regressed, thyroid function was normalized. Propranolol may have adverse effects including hypotension, hypoglycemia, bronchoconstriction, and restlessness, but she did not experience such adverse effects. Propranolol could be the first choice for diffuse neonatal hemangiomatosis (DNH). Our case also suggests that thyroid function test is needed in patient with DNH.

The effects of daily bathing on symptoms of patients with bronchial asthma

BACKGROUND: The influence of bathing in asthma patients is not yet fully known. OBJECTIVE: We conducted an observational study to investigate changes in symptoms and their degree by bathing in asthmatic patients. METHODS: A questionnaire focusing on ever experienced bathing-induced symptom changes and their degree, as well as contributing factors, was designed and administered to asthmatic patients in the outpatient department of our institute between January 2012 and November 2013. RESULTS: Two hundred fifteen cases were recruited. In 60 cases (27.9%), asthmatic symptoms appeared, including 20 cases of chest discomfort (33.3%), 19 cases of cough (31.7%), and 21 cases of wheezing (35.0%). The triggering factors included vapor inhalation (32 cases, 53.3%), hydrostatic pressure on the thorax due to body immersion in the bathtub (26 cases, 43.3%), and sudden change of air temperature (16 cases, 26.7%). Thirty-eight cases (17.7%) experienced improvement in active asthmatic symptoms by bathing. Vapor inhalation was the most common contributing factor (34 cases, 89.5%), followed by warming of the whole body (13 cases, 34.2%). There was no relationship between asthma severity and the appearance of bathing-induced symptoms or improvement of active asthmatic symptoms by bathing. CONCLUSION: The effects of bathing in asthmatic patients widely differed from patient to patient and their etiology includes several factors. For those who suffer from bathing-induced asthma symptoms, preventive methods, such as premedication with bronchodilators before bathing, should be established. This study is registered in the University Hospital Medical Information Network (UMIN) clinical trials registry in Japan with the registration number UMIN000015641.

A Case of Diffuse Neonatal Hemangiomatosis Successfully Treated with Propranolol / 임상소아혈액종양

We present a case of a 41-day-old girl with diffuse hemangiomatosis on her chin, right thigh, occipital area, and liver. She also had hepatomegaly, heart failure, and hypothyroidism. Hemangiomatosis did not respond to 2 weeks of oral administration of prednisolone, but was successfully treated with propranolol. After 2 years of propranolol treatment, the lesions of hemangiomatosis nearly disappeared. Hypothyroidism was controlled by levothyroxine replacement. As hemangiomatosis regressed, thyroid function was normalized. Propranolol may have adverse effects including hypotension, hypoglycemia, bronchoconstriction, and restlessness, but she did not experience such adverse effects. Propranolol could be the first choice for diffuse neonatal hemangiomatosis (DNH). Our case also suggests that thyroid function test is needed in patient with DNH.

Propranolol as a First-line Treatment for Pediatric Hemangioma: Outcome of a Single Institution Over One Year / 임상소아혈액종양

BACKGROUND: Propranolol, a beta-blocker and well known anti-hypertensive medication, has been used as the first-line therapy for pediatric hemangioma since 2010. The objective of this study is to analyze the efficacy and safety of propranolol when used to treat pediatric hemangioma patients for one year or longer in a single institution. METHODS: A retrospective chart review analysis was done of 65 pediatric hemangioma patients treated with oral propranolol as the first-line therapy from 2010 to 2016. The patients were examined regularly at an interval of 1 to 2 months for changes in hemangioma size, growth and development, and occurrence of acute side effects of propranolol such as hypotension, hypoglycemia and bronchial constriction. RESULTS: Twenty patients were treated with propranolol for a year or longer and their median age was 202 days (range, 36 to 4,284 days) and mean duration of treatment was 22.5 months (range, 12 to 49 months). At 12 months of treatment, the average percentage of size decrement was 40.5%. When the weight and height percentile were compared between at diagnosis and 12 months post-treatment, all 20 patients showed normal growth curve and development. Patients did not show any acute side effects of propranolol during 12 months of treatment. One patient experienced hypoglycemia induced seizure, but this event was subsequently diagnosed as ketotic hypoglycemia induced from prolonged fasting. CONCLUSION: Propranolol was effective and well tolerated in children with hemangioma when used for one year or longer.

The association of forced expiratory volume in one second and forced expiratory flow at 50% of the vital capacity, peak expiratory flow parameters, and blood eosinophil counts in exercise-induced bronchospasm in children with mild asthma

BACKGROUND: Exercise-induced bronchoconstriction (EIB), which describes acute airway narrowing that occurs as a result of exercise, is associated with eosinophilic airway inflammation, bronchial hyperresponsiveness. The forced expiratory volume in one second (FEV₁) is the most commonly used spirometric test in the diagnosis of EIB in exercise challenge in asthma. Other parameters such as forced expiratory flow at 50% of the vital capacity (FEF(50%)) and peak expiratory flow (PEF) are used less often in the diagnosis of EIB. OBJECTIVE: The purpose of this study is to evaluate the association of FEV₁ and FEF(50%), PEF parameters, blood eosinophil counts in EIB in children with mild asthma. METHODS: Sixty-seven children (male: 39, female: 28) with mild asthma were included in this study. Pulmonary functions were assessed before and at 1, 5, 10, 15, and 20 minutes after exercise. The values of spirometric FEV₁, FEF50(%), PEF, and blood eosinophil counts were evaluated in EIB in children with mild asthma. RESULTS: There was a positive correlation between FEV₁ with FEF(50%) and PEF values (p < 0.05; FEF(50%), r=0.68; PEF, r=0.65). Also, a positive correlation was found between blood eosinophil counts and the values of spirometric FEV₁, FEF(50%), and PEF (p < 0.05; FEV₁, r=0.54; FEF(50%), r=0.42; PEF, r=0.26). In addition to these correlations, in the exercise negative group for FEV₁, the FEF(50%) and PEF values decreased more than the cutoff values in 3, and 2 patients, respectively. CONCLUSION: According to the presented study, eosinophil may play a major role in the severity of EIB in mild asthma. FEF(50%) and PEF values can decrease in response to exercise without changes in FEV₁ in mild asthmatic patients.

Plasma secreted phospholipase A2 in asthmatic children: correlation with leptin levels and exercise induced bronchoconstriction

PURPOSE: Dysregulated cysteinyl leukotriene (CysLT) synthesis is prominent in exercise-induced bronchoconstriction (EIB). Secreted phospholipase A2 (sPLA2) plays a key regulatory role in the biosynthesis of CysLTs. We previously found that serum leptin levels correlate with (EIB) in children with asthma. The aim of this study was to address the relationship between plasma sPLA2/leptin levels and EIB. METHODS: Sixty-seven prepubertal children between the ages of 6 and 10 years were included in the study. They were asthmatics with EIB (n=25), asthmatics without EIB (n=21), and healthy subjects (n=21). We measured the plasma sPLA2 and leptin levels. We also performed pulmonary function tests at baseline, after bronchodilator inhalation, and after exercise. RESULTS: The sPLA2 and leptin levels were significantly higher in asthmatics with EIB than in those without and control subjects. In addition, sPLA2 levels were significantly correlated with body mass index (Speraman correlation coefficient r=0.343, P=0.023) and leptin levels (partial correlation coefficient r=318, P=0.033). The maximum decrease in % forced expiratory volume in 1 second after exercise was significantly correlated with both PLA2 levels (r=0.301, P=0.041) and leptin levels (r=0.346, P=0.018). CONCLUSION: The sPLA2 and leptin levels were significantly higher in asthmatics with EIB than in asthmatics without EIB and control subjects. In addition, sPLA2 levels were significantly correlated with leptin levels and EIB in asthmatic children.

The role of leukotriene modifier in pediatric allergic disease

Leukotriene (LT) modifiers are composed of leukotriene receptor antagonists and 5-lipoxygenase inhibitors. LTs, C4, D4, and E4 are collectively termed cysteinyl LTs and best are the characterized receptors for cysLTs are cysLT1 and cysLT2. cysLT1 ligation mediates sustained bronchial contraction, mucosal secretion, and edema, which are central to the pathogenesis of asthma. cysLT2 ligation is thought to contribute to edema, inflammation, and tissue fibrosis in asthma. LT modifiers attenuate bronchoconstriction responses and exert anti-inflammatory effects, reflected by reduced eosinophil counts in the peripheral blood, sputum, and bronchoalveolar lavage fluid of asthmatic patients. Inhaled corticosteroids are generally superior to LT modifiers as a first-line controller. However, LT modifiers are easy to administer, have good compliance, and have excellent safety. LT modifiers are recommended for asthmatic children aged < or =5 years as a first-line controller. The Japanese Guideline for Childhood Asthma recommends LT modifiers, as a first-line controller prior to inhaled corticosteroid for children aged <2 years. LT modifiers can improve asthma control as add-on therapy with ICS. They can also be effective for exercise-induced asthma. LT modifiers are recommended for the treatment of allergic rhinitis in combination with H1-antihistamines or as a first-line drug for patients who cannot or do not wish to use intranasal corticosteroids. LT modifiers can also be considered for add-on therapy in the treatment of chronic urticaria, atopic dermatitis, and other allergic diseases.

Bronchoconstriction following instillation of phenylephrine eye drops in premature infants with bronchopulmonary dysplasia: two cases report / 대한마취과학회지

Premature infants requiring an ophthalmic examination or even surgery for retinopathy of prematurity (ROP) have a high prevalence of co-existing bronchopulmonary dysplasia (BPD). Reactive airway is one of the clinical presentations of BPD. We report two cases of bronchoconstriction following instillation of mydriatic eye drops. One occurred during induction of anesthesia for laser photocoagulation and the other before screening of ROP. The most likely cause in each case was phenylephrine eye drops. We recommend that the minimal dosage of phenylephrine needed to attain proper mydriasis should be instilled to infant patients, and the possibility of bronchoconstriction occurrence kept in mind, especially for infants with low body weight with BPD.

Medicinas tradicionales andinas y su despenalización: entrevista con Walter Álvarez Quispe / Decriminalizing traditional Andean medicine: an interview with Walter Álvarez Quispe

Walter Álvarez Quispe, terapeuta kallawaya y biomédico especializado en cirugía general y ginecología, presenta la lucha de los terapeutas tradicionales y alternativos por la depenalización de estos sistemas médicos andinos realizada entre 1960 y 1990. Bolivia se torna el primer país en América Latina y el Caribe en despenalizar la medicina tradicional antes de los planteamientos de la Conferencia Internacional sobre Atención Primaria de Salud (Alma-Ata, 1978). Los datos aportados por el entrevistado aseguran que los logros alcanzados, principalmente por los kallawayas, responden a un proyecto propio y autónomo. Estas conquistas no se deben a las políticas oficiales de interculturalidad en salud, aunque busquen atribuirse para sí los logros alcanzados.

Walter Álvarez Quispe, a Kallawaya healer and biomedical practitioner specializing in general surgery and gynecology, presents the struggle of traditional and alternative healers to get their Andean medical systems depenalized between 1960 and 1990. Bolivia was the first country in Latin America and the Caribbean to decriminalize traditional medicine before the proposals of the International Conference on Primary Health Care (Alma-Ata, 1978). The data provided by the interviewee show that the successes achieved, mainly by the Kallawayas, stem from their own independent initiative. These victories are not the result of official policies of interculturality in healthcare, although the successes achieved tend to be ascribed to them.

Estenosis bronquial congénita, papel de las imágenes en el diagnóstico: presentación de un caso / The role of diagnostic imaging in congenital bronchial stenosis: A Case report

En este artículo se presenta el caso de un lactante menor de 2 meses de edad que a los 15 días de nacido presentó estridor y dificultad respiratoria, por lo que fue llevado a una clínica de primer nivel, donde se le realizó una radiografía de tórax en la cual se documentó la presencia de una hiperinflación del campo pulmonar derecho. Se le realizó una fibrobroncoscopia óptica, de resultado normal, y una gammagrafía de ventilación/perfusión que mostró una hipoplasia pulmonar derecha. Fue manejado con oxígeno suplementario y terapias respiratorias sin mejoría clínica, motivo por el cual fue trasladado a otra institución para un manejo especializado. Con el fin de obtener un mapa vascular prequirúrgico, se realizó una angiografía pulmonar por tomografía, unas reconstrucciones con mínima intensidad de proyección y una broncoscopia virtual multicorte. Con todo ello se documentó una estenosis del bronquio fuente derecho, producida por un repliegue de la pared bronquial y con efecto de válvula, que producía una hiperinsuflación secundaria del pulmón derecho. Estos hallazgos fueron confirmados en la cirugía correctiva. Este es un caso de gran interés porque, a pesar de lo inusual de la patología y la edad del paciente, fue posible establecer un diagnóstico certero mediante el uso de la TAC multidetector que permitió utilizar herramientas de reconstrucción tridimensional y navegación endoluminal, como la broncoscopia virtual.

This article reports the case of a lactating infant, 2 months old, who 15 days after birth presented gasping and respiratory difficulty. For this reason, he was taken to a first-degree clinic, where a thorax radiography was performed. This thorax radiography documented the presence of a hyper-inflation of the right lung. An optic fiber bronchoscopy was performed, with normal results, and a ventilation/perfusion scan which reported a hypoplasia of the right lung. It was treated with complementary oxygen and respiratory therapies without any clinical improvement. Therefore, the patient was sent to a different institution for more specialized treatment. A pulmonary angiography through a tomography, a minimum projection intensity reconstruction, and a multi-slice virtual bronchoscopy were performed in order to obtain a presurgical vascular map. This process showed a stenosis of the right source bronchus, caused by a fold of the bronchial wall with a valve effect, causing a secondary hyperinsuflation of the right lung. These findings were confirmed in the corrective surgery. We consider this case especially interesting because, in spite of the unusual pathology and the age of the patient, it was possible to establish a correct diagnosis through the use of the multi detector CAT scan, enabling us to use the reconstructive three-dimensional tools, as well as endoluminal navigation such as virtual bronchoscopy.

Massive Cardiomegaly due to Dilated Cardiomyopathy Causing Bronchial Obstruction in an Infant

Dilated cardiomyopathy (DCMP) remains a life threatening disease in young patients and is often difficult to differentiate from myocarditis. Early recognition and treatment of DCMP are crucial for good prognoses in this patient population. The clinical course of patients with DCMP that result in cardiogenic shock varies according to the etiology as well as patient age. The volumetric expansion of the enlarged heart can compress adjacent structures causing a number of related symptoms, especially in infants with soft cartilaginous bronchi. Therapeutic strategies for treating these issues vary according to the type of complication encountered. We report a case of severe DCMP with sudden onset of massive cardiomegaly with heart failure complicated by bronchial obstruction in an infant.