People with asthma: care during the COVID-19 pandemic and the importance of regular exercise for the immune system

Abstract Aim: To show the possible immunologic pathways of protection for asthmatics against infection of Covid-19 through the capacity of recognition and cytotoxicity to eliminate pathogens improved by regular exercise aerobic. Methods: The bibliographic search was conducted on the following databases: Pubmed/Medline, Scielo, and Scholar Google from 2020 to 2021. The following keywords and Boolean operators were used: asthma, aerobic training (AT), immune system, and Covid-19. Results: After the screening, 349 were initially found, after evaluation only 20 studies had all criteria. Twelve studies showed that AT induces changes in the immune system with a reduction of inflammation. In complement, the literature showed an innate pathway that improves immune function against COVID-19 by reducing angiotensin-converting enzyme 2 (ACE2) in the lung, which seems to hinder the multiplication of the COVID-19 virus in the lung. Apparently, asthmatics patients are less susceptible to respiratory infection caused by COVID-19 because they have low levels of ACE2. Furthermore, trained asthmatics showed a lower risk of infection for SARS-CoV-2. Conclusion: The findings reported that asthmatics people can benefit from AT, and these individuals seem not to be a risk group for covid-19 because they have low levels of ACE2 protein. Taken together, this review reinforces the importance of asthmatic patients be physically active throughout their lifetime, but specially during the pandemic to prevent contamination by SARS-CoV-2.

Alteraciones de la función pulmonar medida por espirometría y oscilometría de impulso en niños asmáticos con sobrepeso y obesidad / Alterations in lung function as measured by spirometry and impulse oscillometry in asthmatic children with overweight and obesity

INTRODUCCIÓN: El incremento del índice de masa corporal afecta la función pulmonar en el asma. Objetivo: determinar si existen diferencias entre asmáticos con estado nutricional normal, sobrepeso y obesidad en cuanto a alteraciones de la oscilometría de impulso (IOS) y espirometría. MÉTODO: Estudio realizado en niños y adolescentes con asma persistente. Se practicó sucesivamente IOS y Espirometría pre y post- broncodilatador según criterios ATS/ERS/SER. Los pacientes se clasificaron en: eutróficos (AE), con sobrepeso (ASP) y obesos (AO). Se compararon promedios de valores basales y con respuesta broncodilatadora (RB) en espirometría e IOS, con análisis de varianzas ANOVA y test de Tukey post hoc. Se consideró un poder de 80% y error α de 5%. RESULTADOS: Se analizaron 559 pacientes, promedio de edad 9,2 años, 50,9% varones. AE 52,4%, ASP 31,3% y AO 16,3%. Se encontraron diferencias significativas entre AO vs AE (X5, AX, D5-20, VEF1/CVF, FEF25-75/CVF, RB VEF1), y entre ASP vs AE (AX, D5-20, VEF1/CVF). También se encontraron diferencias significativas en varones, no encontradas en las mujeres (X5, D5-20, VEF1/CVF, RB CVF, RB VEF1). CONCLUSIONES: Los niños asmáticos con sobrepeso y obesidad, tienen un mayor compromiso de los índices de función pulmonar medida por espirometría e IOS que los asmáticos con estado nutricional normal. Existen diferencias de género en las alteraciones espirometría e IOS.

INTRODUCTION: Increased body mass index asthma affects lung function in asthma. Objective: to determine if asthmatics with overweight or obesity have alterations in Impulse oscillometry (IOS) and spirometry compared to eutrophic METHOD: Study carried out in children and adolescents with persistent asthma. IOS-Spirometry pre and post bronchodilator were performed successively according to ATS/ERS/SER criteria. The patients were classified as: eutrophic (AE), overweight (ASP) and obese (OA). Baseline and bronchodilator response (BR) averages were compared in spirometry and IOS with ANOVA and Tukey's post hoc analysis of variance. A power of 80% and α error of 5% were considered. RESULTS: 559 patients were analyzed, mean age 9.2 years, 50.9% male. AE 52.4%, ASP 31.3% and OA 16.3%. Significant differences were found between OA vs AE (X5, AX, D5-20, FEV1/FVC, FEF25-75 / FVC, RB FEV1), and between ASP vs AE (AX, D5-20, FEV1/FVC). Significant differences were also found in men, not women (X5, D5-20, FEV1/FVC, BR FVC, BR FEV1). CONCLUSIONS: Asthmatic children with overweight and obesity have a greater compromise of pulmonary function parameters measured by spirometry and IOS than asthmatics with normal nutritional status. There are gender differences in spirometry and IOS alterations.

Relationship between schoolchildrens levels of physical activity, anthropometric indices and pulmonary function / Relação entre níveis de atividade física, índices antropométricos e função pulmonar de escolares

ABSTRACT Objective: To evaluate and to correlate levels of physical activity with the pulmonary function of children with and without a diagnosis of asthma. Methods: This study was conducted in two phases with schoolchildren aged between eight and 16 years old in Porto Alegre/RS. In the first phase (cross sectional), the sample was classified as asthmatic if a physician had ever diagnosed them with asthma and if they reported symptoms and treatment for the disease in the past 12 months. In the second phase (control-case), the following were measured: anthropometry, physical activity levels, time spent in front of screens, and lung function (spirometry). Data are presented in mean and standard deviation or median and interquartile interval and by absolute and relative values. Chi-square, Student's t-test or Mann-Whitney test and Spearman correlation were applied, with p<0.05 being significant. Results: 605 students participated in the study, 290 children with a clinical diagnosis of asthma and 315 classified as a control. 280 (47.3%) were male children, with an average age of 11.0±2.3 years old. The spirometric values showed differences in the classifications of airway obstruction levels between the asthma and control groups (p=0.005), as well as in the response to bronchodilator use for FEV1/FVC (p=0.023). In the correlation assessment, there was no correlation between physical activity with anthropometric values, nor with pulmonary function, pre-and post-bronchodilator. Conclusions: The study demonstrates that there is no relationship between either anthropometric values or physical activity levels with pulmonary function of asthmatic children.

RESUMO Objetivo: Avaliar e correlacionar os níveis de atividade física com a função pulmonar de crianças com e sem diagnóstico de asma. Métodos: Estudo realizado em duas fases, em escolares de oito a 16 anos de Porto Alegre (RS). Na fase I (transversal), classificaram-se como asmáticos os escolares com diagnóstico positivo de um médico alguma vez na vida, com crises e tratamento para a doença nos últimos 12 meses. Na fase II (caso controle), foram avaliados: antropometria, níveis de atividade física e tempo gasto em frente às telas e função pulmonar (espirometria). Os dados são apresentados por média e desvio padrão ou mediana e intervalo interquartil e por valores absolutos e relativos, sendo aplicados os testes χ2, t de Student ou de Mann-Whitney e correlação de Spearman, com valor de significância p<0,05. Resultados: Participaram do estudo 605 escolares, 290 crianças com diagnóstico clínico de asma e 315 classificadas como controle. Do total, 280 (47,3%) crianças eram do sexo masculino, com média de idade de 11,0±2,3 anos. Os valores espirométricos demonstraram diferenças nas classificações dos níveis de obstrução das vias aéreas entre grupos asma e controle (p=0,005), além da resposta ao uso de broncodilatador, para o volume expiratório forçado no primeiro segundo (VEF1)/capacidade vital forçada (CVF) (p=0,023). Não houve correlação entre a prática de atividades físicas e valores antropométricos, tampouco entre a função pulmonar e o pré e pós-uso de broncodilatador. Conclusões: O estudo demonstrou não existir relação entre valores antropométricos e níveis de atividade física com a função pulmonar de crianças asmáticas em idade escolar.

Técnica de oscilações forçadas na avaliação e manejo de crianças asmáticas: uma revisão narrativa / Forced oscillation technique in the assessment and management of asthmatic children: a narrative review

Asthma is considered the most prevalent chronic disease in children. The pulmonary function measurements are important in the evaluation of the disease, being able to confirm the diagnosis by demonstrating the reversibility of the obstruction as well as detecting risks of poor prognosis in the control of asthma. However, the most common methods for analyzing pulmonary function in this age group have restrictions on its applicability, especially due to the need for cooperation on the part of patients. The forced oscillation technique (FOT) is considered a modern tool capable of estimating measures of respiratory mechanics related to the lungs. This method is easily applicable due to the low need for patient cooperation, an important element in the assessment of children. The aim of this study is to review the clinical utility of the Forced Oscillation Technique in the pulmonary assessment of asthmatic children. The bibliographic search covered the years between 1950 and 2019, in the databases: Medical Literature Analysis and Retrieval System Online (MEDLINE) and Latin American and Caribbean Literature in Health Sciences (LILACS). It was used as a search strategy the combination of the following Medical Subject Headings (MeSH) terms: "asthma", "oscillometry" and "child" crossed through the AND and OR Boolean connectors. In asthmatic children, FOT showed greater accuracy in the evaluation of smaller caliber peripheral airways, which can be applied as a complementary method to spirometry to strengthen the diagnosis, enabling a better understanding of the disease and its progression.

A asma é considerada a doença crônica de maior incidência em crianças. As medidas de função pulmonar são importantes na avaliação da doença, podendo confirmar o diagnóstico pela demonstração de reversibilidade da obstrução assim como detectar riscos de mau prognóstico no controle da asma. Entretanto, os métodos mais usuais para análise da função pulmonar nesta faixa etária apresentam restrições em sua aplicabilidade, especialmente pela necessidade de cooperação por parte dos pacientes. A técnica de oscilações forçadas (FOT) é considerada uma ferramenta moderna capaz de estimar medidas da mecânica respiratória relativas aos pulmões. Este método apresenta fácil aplicabilidade pela baixa necessidade de cooperação do paciente, elemento importante na avaliação de crianças. O objetivo deste estudo é revisar a utilidade clínica da Técnica de Oscilações Forçadas na avaliação pulmonar de crianças asmáticas. A busca bibliográfica contemplou os anos entre 1950 e 2019, nas bases de dados: Medical Literature Analysis and Retrieval System Online (MEDLINE) e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). Foi utilizada como estratégia de busca a combinação dos seguintes Medical Subject Headings(MeSH) terms: "asthma", "oscillometry" e "child" cruzados por meio dos conectores booleanos AND e OR. Em crianças asmáticas, a FOT mostrou maior acurácia na avaliação de vias aéreas periféricas de menor calibre, podendo ser aplicada como método complementar a espirometria para encorpar o diagnóstico, possibilitando compreender melhor a doença e sua progressão.

Consenso chileno SOCHINEP-SER para el diagnóstico y tratamiento del asma en el escolar / Chilean SOCHINEP-SER consensus for asthma diagnosis and treatment in school age children

Bronchial asthma is the most prevalent chronic condition among children, however, in Chile, it is underdiagnosed. This may be due to medical professionals failing to recognize the disease. It is essential to be aware of the symptoms and signs that are suggestive of the disease in order to begin an appropriate treatment to achieve disease control. Asthma must be suspected in school age children who present repeated episodes of bronchial obstruction. The diagnosis should be confirmed with lung function tests that demonstrate variable airflow obstruction with a positive bronchodilator response. Treatment is based on two fundamental pillars: education and pharmacological treatment. Educational activities must include: information about the disease and its treatment, regular monitoring of treatment adherence, teaching and reviewing the correct inhalation technique at every checkup, developing a personalized written action plan and scheduling regular follow-up appointments. The gold standard for treatment is maintenance inhaled corticosteroids, in the lowest possible dose that enables disease control. The goal of the treatment is to eliminate daily symptoms and asthma crisis. Therapy should be increased if control is not achieved, but before starting it, adherence to maintenance treatment, inhalation technique, presence of associated comorbidities and environmental exposure should be evaluated. In the mild patient, who is not receiving maintenance therapy, rescue treatment should be done with bronchodilators, always associated with inhaled corticosteroids. This consensus is a guide to improve the diagnosis, treatment and control of asthma in schoolchildren.

El asma bronquial es la enfermedad crónica más frecuente en la infancia. Sin embargo en Chile existe un importante subdiagnóstico. Es fundamental estar atentos a los síntomas y signos que nos hacen sospechar el diagnóstico para iniciar un tratamiento oportuno, que asegure un buen control de la enfermedad. Debemos sospechar asma en todo escolar que presente cuadros repetidos de obstrucción bronquial. El diagnóstico debe confirmarse con pruebas de función pulmonar que demuestren obstrucción variable al flujo aéreo y respuesta broncodilatadora positiva. El tratamiento se basa en dos pilares fundamentales: la educación y el tratamiento farmacológico. Las actividades educativas deben incluir contenidos acerca de la enfermedad y su tratamiento, se debe monitorizar constantemente la adherencia al tratamiento de mantención, enseñar la técnica inhalatoria correcta y revisar en cada control, entregar un plan de acción escrito personalizado frente al inicio de una crisis y realizar controles médicos periódicos. Con respecto al tratamiento farmacológico, el estándar de oro es el uso de corticoides inhalados permanentes, en la mínima dosis posible que logre el control de la enfermedad. El objetivo del tratamiento es la supresión de los síntomas diarios y de las crisis. El tratamiento se irá incrementando en la medida que no haya una respuesta adecuada, pero antes de aquello se debe evaluar la adherencia al tratamiento de mantención, la técnica inhalatoria, presencia de comorbilidades asociadas y exposición ambiental. En el paciente leve, que esté sin tratamiento permanente, el rescate debe realizarse con broncodilatadores asociados siempre a un corticoide inhalado. Este consenso es una guía de apoyo para mejorar el diagnóstico oportuno, tratamiento y control del asma en el escolar.

¿Son las mascotas, perro o gato, un factor de riesgo o protector para el desarrollo o exacerbación del asma? Revisión sistemática de revisiones sistemáticas / Are pets, dog or cat, a risk or a protector factor for the development or exacerbation of asthma? Systematic review of systematic reviews

RESUMEN Antecedentes Estudios previos han mostrado resultados contradictorios de la asociación entre la exposición a mascotas (gato o perro) y asma. La evidencia científica previa no ha sido clara en definir si evitar o permitir la exposición puede prevenir, mejorar o empeorar el desarrollo del asma o de sus síntomas. Objetivo Intentar dilucidar la relación controversial que existe entre la exposición a las mascotas, perro o gato, y su efecto en el desarrollo del asma, o la exacerbación de sus síntomas, tanto en niños como en adultos. Metodo Se realizó una búsqueda estandarizada en cinco bases de datos electrónicas por parte de un evaluador independiente. La muestra final de estudios incluidos en la revisión sistemática de revisiones sistemáticas fue tamizada y sintetizada mediante una tabla maestra. Se realizó una descripción narrativa de los resultados. Resultados En esta revisión sistemática de revisiones sistemáticas se encontró principalmente que tener gato podría ser un factor de riesgo y tener perro un factor protector para el desarrollo del asma. No obstante, la exposición temprana a cualquiera de las dos mascotas (antes de cumplir 2 años) disminuye la probabilidad de desarrollar síntomas de asma y sibilancias en la edad escolar. Además, tener un antecedente de sensibilización a los alergenos de dichas mascotas puede convertirse en un factor de riesgo para la exacerbación del asma, tanto en niños como en adultos.(AU)

ABSTRACT Background Preliminary studies have shown conflicting results on the association between exposure to pets (cat or dog) and asthma. Previous scientific evidence has not been clear to determine if avoiding or allowing the exposure to pets could prevent, improve, or worsen the development of asthma and its symptoms. Objective To try to explain the controversial relationship between exposure to pets (dog or cat) and its effect on the development of asthma or the exacerbation of symptoms in both children and adults. Methods A standardized search in five electronic databases by an independent reviewer was carried out. The final sample of studies included in the overview of systematic reviews was screened and synthesized through a master table. A narrative description of the results was made. Results This systematic review of systematic found determined principally that having a cat could be a risk factor and having a dog a protective factor in the development of asthma. However, early exposure to both cats and dogs (before the age of two) reduces the probability of asthma symptoms and wheezing in the school years. Additionally, having antecedents of sensibilization to pets allergen could be a risk factor to exacerbate asthma in both children and adults.(AU)

Comparison between the health-related quality of life of children/adolescents with asthma and that of their caregivers: a systematic review and meta-analysis / Comparação da qualidade de vida relacionada à saúde de crianças/adolescentes com asma e de seus cuidadores: uma revisão sistemática e meta-análise

ABSTRACT Objective: To evaluate the health-related quality of life (HRQoL) of children/adolescents with asthma and that of their caregivers, comparing the two. Methods: This was a systematic review and meta-analysis based on the criteria of Preferred Reporting Items for Systematic Reviews and Meta-Analyses, with a strategy of searching five health-related databases (MEDLINE/PubMed, EMBASE, ScienceDirect, SciELO, and LILACS). We included studies that evaluated the HRQoL of children/adolescents with asthma and that of their caregivers with the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire, respectively, using the total scores and the scores on the domains activity limitation, symptoms (children/adolescents only), and emotional function. Results: We identified 291 articles, and we evaluated 133 of those. A total of 33 articles, collectively including 4,101 subjects, were included in the meta-analysis. An analysis stratified by study design showed no differences between the HRQoL of the caregivers and that of the children/adolescents in the activity limitation domain and in the total score. However, the mean emotional function domain scores were significantly higher (better) among children/adolescents with asthma than among their caregivers in longitudinal studies-Δ = 0.82 (0.21-1.44)-and randomized clinical trials-Δ = 0.52 (0.29-0.79)-although not in cross-sectional studies-Δ = −0.20 (−0.03 to 0.43). Conclusions: The total HRQoL scores proved to be similar between children/adolescents with asthma and their caregivers. However, the two groups differed in their perception of their emotional function, the caregivers scoring significantly lower than the children/adolescents in that domain.

RESUMO Objetivo: Avaliar e comparar os níveis de qualidade de vida relacionada à saúde (QVRS) de crianças/adolescentes com asma e de seus cuidadores. Métodos: Revisão sistemática e meta-análise baseada nos critérios de Preferred Reporting Items for Systematic Reviews and Meta-Analyses, com estratégia de busca em cinco bases de dados em saúde (MEDLINE/PubMed, EMBASE, ScienceDirect, SciELO e LILACS). Foram incluídos estudos que avaliaram a QVRS de crianças/adolescentes com asma e de seus cuidadores por meio dos escores totais e dos domínios limitação de atividades, sintomas (somente crianças/adolescentes) e função emocional do Pediatric Asthma Quality of Life Questionnaire e do Pediatric Asthma Caregiver's Quality of Life Questionnaire, respectivamente. Resultados: Do total de 291 artigos identificados, 133 foram avaliados e 33 foram incluídos na meta-análise, totalizando 4.101 sujeitos. A análise estratificada por tipo de delineamento não mostrou diferenças entre a QVRS de cuidadores e de crianças/adolescentes no domínio limitação de atividades e no escore total. Contudo, houve diferenças das médias no domínio função emocional em estudos longitudinais e ensaios clínicos randomizados - estudos transversais: Δ = −0,20 (−0,03 a 0,43); estudos longitudinais: Δ = 0,82 (0,21-1,44); e ensaios clínicos randomizados: Δ = 0,52 (0,29-0,79) - sendo que os cuidadores apresentaram menores escores que as crianças/adolescentes com asma. Conclusões: Os escores da QVRS entre cuidadores e crianças/adolescentes com asma demonstraram ser semelhantes quanto aos escores totais, mas divergiram na percepção das limitações emocionais, visto que os cuidadores apresentaram escores significativamente menores que as crianças/adolescentes nesse domínio.

Avaliação do controle da asma entre diferentes medidas e avaliação da capacidade de exercício funcional em crianças e adolescentes com asma / Assessment of asthma control among different measures and evaluation of functional exercise capacity in children and adolescents with asthma

RESUMO Objetivo Avaliar a concordância entre as medidas de controle da asma e a capacidade de exercício funcional em crianças e adolescentes com asma não controlada e controlada. Métodos Selecionamos crianças e adolescentes com asma de 7 a 17 anos, que foram atendidos no Ambulatório de Pneumologia Pediátrica da Universidade Estadual de Campinas. Todos os pacientes tiveram nível de controle da asma avaliado pelo questionário da Global Initiative for Asthma (GINAq), Teste de Controle da Asma (TCA), espirometria e teste de caminhada de seis minutos (TC6M). Os pacientes foram classificados como asma não controlada ou controlada em cada teste e a concordância entre as medidas foi avaliada pelas estatísticas do Kappa. A curva ROC foi calculada para o TC6M. O índice espirométrico da espirometria foi composto por FEV1, FEV1/FVC e FEF25-75%. Os resultados da espirometria e do TC6M foram comparados entre o grupo de asma não controlada e controlada pela GINAq. Resultados Dos 138 sujeitos incluídos, 78 (56,5%) eram do sexo masculino com idade média de 11,00 (7-17) anos. O GINAq detectou 68,8% dos pacientes com asma não controlada. Foi observada concordância moderada (p<0,001; k=0,56) e alta especificidade (100%) entre o GINAq e o TCA. No TC6M, o ponto de corte de 82,03% da distância prevista possibilitou a distinção de pacientes com asma controlada e não controlada. O índice espirométrico apresentou 73,4% de sensibilidade com o GINAq. Foram observados resultados piores no TC6M em pacientes com asma não controlada. Conclusões Este estudo destaca a importância de avaliar mais de uma medida para diferenciar o nível de controle da asma. O GINAq identificou mais pacientes com asma não controlada e apresentou concordância moderada com o TCA. O índice espirométrico foi associado à asma não controlada de acordo com o GINAq. O TC6M foi uma boa medida para distinguir pacientes com asma controlada e não controlada.

ABSTRACT Objective To assess the agreement among asthma control measures and functional exercise capacity in children and adolescents with uncontrolled and controlled asthma. Methods Children and adolescents with asthma from 7-17 years old were selected, and they were attended in the "Pediatric Pulmonology Outpatient Clinic of State University of Campinas", in Brazil. All patients had asthma control level assessed by Global Initiative for Asthma questionnaire (GINAq), Asthma Control Test (ACT), spirometry and six-minute-walk-test (6MWT). Patients were classified as uncontrolled or controlled asthma in each test and agreement among measures was assessed by kappa statistics. The ROC curve was calculated for the 6MWT. The spirometric index obtained from spirometry was composed by FEV1, FEV1/FVC and FEF25-75%. Spirometry and 6MWT results were compared between uncontrolled and controlled asthma group by GINAq. Results Of the 138 subjects included, 78 (56.5%) were male with median age of 11 (7-17) years old. GINAq detected 68.8% of patients with uncontrolled asthma. Moderate agreement (p < 0.001; k = 0.56) and high specificity (100%) was observed between GINAq and ACT. In 6MWT, the cut-off point of 82.03% of predicted distance was able to distinguish patients with controlled and uncontrolled asthma. Spirometric index presented 73.4% of sensitivity according to GINAq. The results for 6MWT in patients with uncontrolled asthma were the worst of all. Conclusion This study highlights the importance of assessing more than one measure to differentiate asthma control level. GINAq identified more patients with uncontrolled asthma and presented moderate agreement with ACT. Spirometric index was associated with uncontrolled asthma according to GINAq. 6MWT was a suitable measure to distinguish patients with controlled and uncontrolled asthma.

Obesidad infantil y asma bronquial / Child Obesity and bronchial asthma

Obesity and bronchial asthma have suffered a sustained increase in its prevalence worldwide. The relationship between both entities has been widely studied especially in the adult population. Obesity has been shown to be a risk factor for new bronchial asthma diagnoses and vice versa; and that both alter the evolution of the other. The relationship between them is based on systemic inflammatory factors and cardiometabolic factors rather than the fat load. In this review we will focus on the pathophysiology of metabolic and immunological alterations that link both diseases.

Obesidad y asma bronquial han sufrido un aumento sostenido de su prevalencia a nivel mundial. La relación entre ambas entidades ha sido ampliamente estudiada especialmente en población adulta. Se ha demostrado que obesidad es un factor de riesgo de nuevos diagnósticos de asma bronquial y viceversa; y que ambas alteran la evolución de la otra. La relación entre ellas se sustenta en factores inflamatorios sistémicos y factores cardiometabólicos más que en la carga adiposa. En esta revisión nos centraremos en la fisiopatología de las alteraciones metabólicas e inmunológicas que ligan ambas enfermedades.

Los efectos del entrenamiento físico en niños asmáticos / Effects of exercise training in children with asthma

Asthma is a chronic obstructive respiratory disease with high prevalence in children. Several factors may trigger asthma symptoms, including exercise, which can lead to exercise-induced bronchoconstriction (EIB). Although physical exercise may represent a risk factor for triggering bronchial obstruction in asthmatics, studies have also indicated several positive effects. Thus, this article aimed to summarize current evidence on the effects of exercise training in children with asthma. There is substantial available evidence on the topic. Most of the findings show that exercise induce positive effects, including the increase of aerobic fitness, decrease of EIB levels, as well as an increase in both disease control and quality of life levels in asthmatic children. As for possible influencing factors in order to obtain exercise-induced positive effects, an adequate prescription of exercise intensity highlights and should be personalized, as well as established close to the anaerobic threshold. Thus, considering the evidence showing beneficial effects and the fact that the practice of physical exercise consists of a low cost and safe non-pharmacological therapy, supervised, personalized and individual recommendation of exercise training by health professionals are indicated to asthmatic children.

El asma es una enfermedad respiratoria obstructiva crónica con alta prevalencia en niños. Varios factores pueden desencadenar síntomas de asma, incluido el ejercicio, que puede conducir a la broncoconstricción inducida por el ejercicio (BIE). Aunque el ejercicio físico puede representar un factor de riesgo para desencadenar la obstrucción bronquial en los asmáticos, estudios también han indicado varios efectos positivos. Este artículo tiene como objetivo resumir la evidencia actual sobre los efectos del entrenamiento físico en niños con asma. Hay evidencia sustancial disponible sobre el tema. La mayoría de los hallazgos muestran que el ejercicio induce efectos positivos, incluido el aumento de la aptitud aeróbica, la disminución de los niveles de la BEI, así como un aumento tanto en el control de la enfermedad como en los niveles de calidad de vida en niños asmáticos. Se destaca la importancia de una prescripción de la intensidad del ejercicio adecuada y personalizada, cerca del umbral anaeróbico, para obtener los efectos positivos inducidos por el ejercicio. Por lo tanto, considerando la evidencia que muestra efectos beneficiosos y el hecho de que la práctica del ejercicio físico consiste en una terapia no farmacológica, segura y de bajo costo, el entrenamiento físico supervisado, personalizado e individualizado por parte de profesionales de la salud es recomendado para niños asmáticos.

Recurrent wheezing in preterm infants: Prevalence and risk factors / Sibilância recorrente em prematuros: prevalência e fatores de risco

ABSTRACT Objective: To evaluate the prevalence and risk factors associated with progression to recurrent wheezing in preterm infants. Methods: The cross-sectional study was carried out in 2014 and 2015 and analyzed preterm infants born between 2011 and 2012. The search for these children was performed in a university maternity hospital and a Special Immunobiological Reference Center. The evaluation was performed through a questionnaire applied during a telephone interview. Results: The study included 445 children aged 39 (18-54) months. In the univariate analysis, the risk factors with the greatest chance of recurrent wheezing were birth weight <1000 g, gestational age <28 weeks, living with two or more siblings, food allergy, and atopic dermatitis in the child, as well as food allergy and asthma in the parents. In the multivariate analysis, there was a significant association between recurrent wheezing and gestational age at birth <28 weeks, food allergy and atopic dermatitis in the child, and living with two or more children. Of the 445 analyzed subjects, 194 received passive immunization against the respiratory syncytial virus, and 251 preterm infants were not immunized. There was a difference between the gestational age of these subgroups (p < 0.001). The overall prevalence of recurrent wheezing was 27.4% (95% CI: 23.42-31.70), whereas in the children who received passive immunization it was 36.1% (95% CI: 29.55-43.03). Conclusions: Personal history of atopy, lower gestational age, and living with two or more children had a significant association with recurrent wheezing. Children with lower gestational age who received passive immunization against the respiratory syncytial virus had a higher prevalence of recurrent wheezing than the group with higher gestational age.

RESUMO Objetivo: Avaliar a prevalência e os fatores de risco associados à evolução para sibilância recorrente em prematuros. Métodos: O estudo transversal foi feito em 2014 e 2015 e analisou crianças prematuras nascidas entre 2011 e 2012. A busca dessas crianças foi feita em maternidade de hospital universitário e em um Centro de Referência para Imunobiológicos Especiais. A avaliação foi feita por questionário dirigido em entrevista telefônica. Resultados: O estudo incluiu 445 crianças com 39 (18-54) meses de vida. Na análise univariada, os fatores de risco com maior chance de sibilância recorrente foram peso de nascimento menor do que 1.000 g, idade gestacional menor do que 28 semanas, convivência com dois ou mais irmãos, alergia alimentar e dermatite atópica na criança e alergia alimentar e asma nos pais. Na análise multivariada houve associação significativa entre sibilância recorrente e idade gestacional ao nascer menor do que 28 semanas, alergia alimentar e dermatite atópica na criança e a convivência com duas ou mais crianças. Dos 445 sujeitos analisados, 194 receberam imunização passiva contra vírus sincicial respiratório e 251 eram prematuros não imunizados. Houve diferença entre a idade gestacional desses subgrupos (p < 0,001). A prevalência geral de sibilância recorrente foi 27,4% (IC 95%: 23,42-31,70) e nas crianças que receberam a imunização passiva foi 36,1% (IC 95%: 29,55-43,03). Conclusões: História pessoal de atopia, menor idade gestacional e convivência com duas ou mais crianças apresentaram associação significativa com sibilância recorrente. As crianças com menor idade gestacional, que receberam a imunização passiva contra o vírus sincicial respiratório, apresentaram maior prevalência de sibilância recorrente que o grupo de maior idade gestacional.

Asthma control in the quality of life levels of asthmatic patients' caregivers: a systematic review with meta-analysis and meta-regression / Controle da asma nos níveis de qualidade de vida de pais de asmáticos: uma revisão sistemática com meta-análise e meta-regressão

Abstract Objective: To perform a systematic review with meta-analysis and meta-regression to correlate the total scores of asthma control with the increase in the total scores of health-related quality of life levels of parents of asthmatic children. Sources: The search was carried out in the following databases: PubMed (MEDLINE); Embase and ScienceDirect (Elsevier); SciELO and LILACs (Bireme) in June 2017. The included studies assessed asthma control through the Asthma Control Questionnaire (ACQ), Asthma Control Test (C-ACT/ACT), and Global Initiative for Asthma (GINA) questionnaires, whereas the Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ) was applied to assess the HRQoL of parents and family members. Summary of the findings: 294 articles were evaluated in the selected databases, of which (n = 38) were excluded for duplicity; (n = 239) after the reading of the titles and abstracts and (n = 5) after reading the studies in full, totaling 12 studies eligible for the meta-analysis. Of the 12 eligible articles, 11 (92%) were published in the last five years, and evaluated children and adolescents aged 1 -20 years, totaling 2804 samples. In the evaluation of the correlation between the disease control scores by ACQ and C-ACT/ACT, the results were satisfactory for both ACQ analyses [R 2: −0.88; p < 0.001], and for C-ACT/ACT [R 2: 0.82; p < 0.001]. Conclusions: The results show that asthma control levels can influence the total HRQoL scores of parents or relatives of children and adolescents with asthma.

Resumo Objetivo: Realizar uma revisão sistemática, com meta-análise e meta-regressão para relacionar os escores totais do controle da asma com o aumento dos escores totais dos níveis de qualidade de vida relacionada à saúde de pais de crianças asmáticas. Fontes: As buscas foram aplicadas nas bases de dados: PubMed (Medline); Embase e ScienceDirect (Elsevier); SciELO e LILACs (Bireme). A busca foi realizada nas bases de dados em saúde em junho de 2017. Os estudos incluídos precisavam ter avaliados o controle da asma pelos questionários Asthma Control Questionnaire (ACQ), Asthma Control Test (C-ACT/ACT) e Global Initiative for Asthma (GINA) e para a QVRS dos pais e familiares o Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ). Resumo dos achados: Foram avaliados 294 artigos nas bases de dados escolhidas, quanto aos níveis de duplicidade nas bases de dados (n = 38), excluídos por falta de enquadramento na leitura dos títulos e resumos (n = 239) e após leitura integral dos estudos (n = 05), restaram 12 estudos elegíveis à meta-análise. Dos 12 artigos elegíveis, 11 (92%) foram publicados nos últimos cinco anos, avaliaram crianças e adolescentes de 1 a 20 anos, total de 2.804 amostras. Na avaliação da correlação entre a pontuação dos escores de controle da doença por ACQ e C-ACT/ACT, os resultados se mostraram satisfatórios tanto para as análises de ACQ [R2: −0.88; p < 0,001], quanto para C-ACT/ACT [R2: 0,82; p < 0,001]. Conclusões: Os resultados demonstram que os níveis de controle da asma podem influenciar nos escores totais da QVRS de pais ou familiares de crianças e adolescentes com asma.

Diaphragm quantitative electromyography in difficult-to-treat asthmatic patients / Eletromiografia quantitativa do diafragma em pacientes com asma de difícil controle

ABSTRACT Quantitative electromyography is an important tool to evaluate myopathies, and some difficult-to-treat asthmatic patients may have a subclinical corticosteroid myopathic process, using only inhaled corticosteroid, according to some studies. In this report, diaphragm quantitative electromyography was used to evaluate asthmatic difficult-to-treat patients, comparing them with a control group. Significant differences were obtained in amplitude, duration and size index of motor unit action potentials, with lower parameters in the asthmatic patients, which may indicate a myopathic process.

RESUMO Eletromiografia quantitativa é uma ferramenta importante para a avaliação de miopatias, e alguns pacientes asmáticos de difícil controle podem ter um processo miopático subclínico, mesmo usando apenas corticosteroides inalatórios, de acordo com alguns artigos. Nesse artigo a eletromiografia quantitativa do diafragma foi usada para avaliar os pacientes asmáticos de difícil controle, comparando com um grupo controle. Diferenças significativas nas amplitudes, durações e índices de tamanho dos potenciais de unidades motoras foram encontradas, com parâmetros mais baixos nos pacientes asmáticos, o que pode indicar um processo miopático.

Actualización en espirometría en el preescolar / Preeschools spirometry update

Spirometry is better pulmonary function test for evaluating preschoolers with chronic lung disease and recurrent wheeze. It is useful, accessible and very good performance. For a correct interpretation it must be under the conditions specially controlled for this age group. In this review, product of the work done during the year 2018, by the Committee on pulmonary function in pediatric pulmonology Chilean society, will be showcased aspects for the realization and interpretation of spirometry in preschool children, with emphasis on the differences in the criteria typically described for older children and adults.

La espirometría es la prueba de función pulmonar más adecuada para evaluar a preescolares con enfermedades pulmonares crónicas y sibilancias recurrentes. Es útil, accesible y de buen rendimiento. Para una correcta interpretación debe realizarse bajo las condiciones especialmente normadas para este grupo etario. En esta revisión, producto del trabajo realizado durante el año 2018, por la comisión de función pulmonar de la sociedad Chilena de Neumología Pediátrica, se expondrán los aspectos actualizados para la realización e interpretación de la espirometría en preescolares, con énfasis en las diferencias de los criterios clásicamente descritos para niños mayores y adultos.

¿Existe asociación entre asma y adiposidad en la población adulta chilena? / Association between adiposity and asthma

Background: In people with asthma, adiposity is associated with more symptoms and less control of the disease whereas on those without asthma adiposity is associated with a higher risk of developing the disease. Aim: To investigate the association between asthma and adiposity markers in Chilean adults. Material and Methods: Data from 5,499 adults older than 15-years-old from the Chilean National Health Survey 20162017 were analyzed. Quintiles of body-mass index (BMI) and waist circumference (WC) were used as a proxy of adiposity. The association between asthma and quintiles of BMI and WC was determined by logistic regression. Results: A higher BMI and WC was associated with a higher odds for asthma. This trend remained significant even after adjusting the models for socio-demographic factors, physical activity and smoking (Odds Ratio [OR] BMI: 1.13 [95% confidence intervals (CI): 1.04; 1.22], p < 0.01 and OR WC: 1.15 [95% IC: 1.06; 1.25], p < 0.01). Conclusions: A higher BMI and WC were positively associated with asthma.

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.

Is a low level of education a limiting factor for asthma control in a population with access to pulmonologists and to treatment? / A baixa escolaridade é um fator limitante para o controle da asma em uma população com acesso a pneumologista e tratamento?

ABSTRACT Objective: To determine whether a low level of education is a risk factor for uncontrolled asthma in a population of patients who have access to pulmonologists and to treatment. Methods: This was a cross-sectional study involving outpatients > 10 years of age diagnosed with asthma who were followed by a pulmonologist for at least 3 months in the city of Jundiai, located in the state of São Paulo, Brazil. The patients completed a questionnaire specifically designed for this study, the 6-item Asthma Control Questionnaire (to assess the control of asthma symptoms), and a questionnaire designed to assess treatment adherence. Patients underwent spirometry, and patient inhaler technique was assessed. Results: 358 patients were enrolled in the study. Level of education was not considered a risk factor for uncontrolled asthma symptoms (OR = 0.99; 95% CI: 0.94-1.05), spirometry findings consistent with obstructive lung disease (OR = 1.00; 95% CI: 0.99-1.01), uncontrolled asthma (OR = 1.03; 95% CI: 0.95-1.10), or the need for moderate/high doses of inhaled medication (OR = 0.99; 95% CI: 0.94-1.06). The number of years of schooling was similar between the patients in whom treatment adherence was good and those in whom it was poor (p = 0.08), as well as between those who demonstrated proper inhaler technique and those who did not (p = 0.41). Conclusions: Among asthma patients with access to pulmonologists and to treatment, a low level of education does not appear to be a limiting factor for adequate asthma control.

RESUMO Objetivo: Avaliar se a baixa escolaridade é um fator de risco para asma não controlada em uma população de pacientes que tem acesso a um pneumologista e ao tratamento. Métodos: Estudo transversal com pacientes com diagnóstico de asma, com idade > 10 anos, acompanhados por ao menos três meses por um pneumologista em ambulatórios na cidade de Jundiaí (SP). Os indivíduos responderam a um questionário específico do estudo, ao Questionário de Controle da Asma com seis questões para avaliar o controle dos sintomas da asma e a um questionário para avaliar a adesão ao tratamento. Avaliou-se a correção no uso de dispositivos inalatórios, e os pacientes realizaram espirometria. Resultados: Foram incluídos 358 pacientes. A escolaridade não foi fator de risco para sintomas de asma não controlados (OR = 0,99; IC95%: 0,94-1,05), presença de distúrbio ventilatório obstrutivo na espirometria (OR = 1,00; IC95%: 0,99-1,01), asma não controlada (OR = 1,03; IC95%: 0,95-1,10) e necessidade de dose moderada/alta de medicações inalatórias (OR = 0,99; IC95%: 0,94-1,06). O número de anos de escolaridade foi semelhante nos grupos com e sem adesão ao tratamento (p = 0,08) e nos grupos com e sem erros na utilização do dispositivo inalatório (p = 0,41). Conclusões: Nesta amostra de pacientes com asma que têm acesso a pneumologista e tratamento, a baixa escolaridade não foi um fator limitante para o controle adequado da asma.

Concentraciones de albúmina modificada por la isquemia en niños con asma: estudio piloto / Ischemia-modified albumin levels in children with asthma: a pilot study

Introducción. La albúmina modificada por la isquemia puede aumentar en el asma (IMA), estrés oxidativo y la inflamación. El objetivo fue evaluar las concentraciones de IMA en niños asmáticos durante períodos asintomáticos y de exacerbación. Población y métodos. Niños asmáticos y sanos en seguimiento (grupo de referencia). La gravedad de la exacerbación se evaluó mediante la Iniciativa global para el asma (GINA) y la puntuación del índice pulmonar modificado (MPIS). Se usaron pruebas intraepidérmicas y de proteína C reactiva para medir las concentraciones séricas de IMA durante la exacerbación y 4 semanas después del tratamiento. Resultados. Participaron 26 pacientes y 26 controles. Las concentraciones medias de IMA durante la exacerbación (0,45 ± 0,12 ABSU) y durante el período de estabilidad (0,41 ± 0,14 ABSU) fueron mayores que en los niños sanos (0,32 ± 0,08 ABSU): p= 0,001 y p= 0,005, respectivamente. No hubo diferencias en IMA al agrupar a los pacientes por tratamiento antiinflamatorio, infección de las vías respiratorias altas previa a la exacerbación, concentraciones de PCR o sensibilidad a las pruebas intraepidérmicas. Las concentraciones fueron más elevadas en los pacientes con exacerbación grave que leve/moderada (p= 0,009). La correlación entre IMA y la gravedad de la exacerbación (r: 0,498; p= 0,010) fue positiva. Conclusiones. Los niños asmáticos presentaron concentraciones de IMA más elevadas que el grupo de referencia, tanto en el período de estabilidad como durante la exacerbación. Hubo una relación positiva entre las concentraciones de IMA y la gravedad de la exacerbación.

Introduction: Hypoxia may occur in the severe exacerbations of asthma. Ischemia-modified albumin (IMA) may increase in ischemia, in addition to oxidative stress and inflammation. The aim was to evaluate IMA levels in children during the asthma exacerbation and the asymptomatic period. Populations and methods: Children with asthma who were followed up in our clinic were included and healthy children were selected as the control group. The severity of exacerbation was evaluated with Global Initiative for Asthma and Modified Pulmonary Index Score. Serum IMA levels were measured at the time of exacerbation and 4 weeks after treatment during asymptomatic period. Skin prick test and C reactive protein (CRP) levels were measured. Results: A total of 26 patients and 26 controls were included. Mean IMA level was 0.45+0.12 absorbance units -ABSU- during asthma exacerbation and 0.32+0.08 ABSU in the control group (p=0.001). Mean IMA levels (0.41+0.14 ABSU) during the stable period were higher than the control group (p=0.005). There was no difference in terms of IMA levels when patients were grouped according to anti-inflammatory treatment, upper respiratory tract infection before exacerbation, CRP levels or sensitivity of skin prick tests. However, IMA levels were higher in patients with severe asthma exacerbation (p=0.009) in comparison with mild/moderate exacerbation. Positive correlation was observed between IMA levels and severity of exacerbation (r: 0.498, p=0.010). Conclusions: Asthmatic children had higher IMA levels than the control group, both in stable and exacerbated asthma. There was a positive relationship between IMA levels and severity of asthma exacerbation.

Prevalencia de la infección por Mycoplasma pneumoniae en pacientes pediátricos con exacerbación aguda del asma / Prevalence of Mycoplasma pneumoniae infection in pediatric patients with acute asthma exacerbation

Introducción. El Mycoplasma pneumoniae puede estar implicado en la exacerbación refractaria del asma, Objetivo. Establecer la prevalencia de la infección por Mycoplasma pneumoniae en pacientes con exacerbación aguda del asma. Material y método. Se realizó un estudio prospectivo, transversal, observacional, caso-control, en pacientes mayores de 2 años y menores de 12. Se determinaron anticuerpos inmunoglobulina M (IgM) para M. pneumoniae por serología por técnica de ensayo por inmunoabsorción ligado a enzima (enzyme-linked immunosorbent assay; ELISA en sus siglas en inglés), utilizando el kit NovaLisa® NovaTec. Se consideró prueba positiva a valores > 11 NTU (NovaTec unidades). El análisis estadístico fue análisis de la varianza (analysis of variance; ANOVA, por sus siglas en inglés) y chi cuadrado con un nivel de significancia de p < 0,05. Resultados. Se estudiaron 180 niños, 130 correspondieron al grupo de niños asmáticos y 50, al grupo control. La IgM específica fue positiva en 60 pacientes, que correspondió al 46,15% de niños asmáticos (p < 0,001). La gravedad de la exacerbación estuvo relacionada directamente con los niveles de IgM (p < 0,001). La tasa de hospitalización fue de 75%, asociada de forma significativa con los niveles de IgM específica (p < 0,001). Conclusión. Nuestros datos sugieren que en los niños con asma aguda, tienen alta prevalencia (46%) de infección por Mycoplasma pneumoniae y estrecha relación entre la exacerbación aguda grave del asma y la infección por Mycoplasma pneumoniae. Estos resultados podrían tener implicaciones terapéuticas orientadas hacia la utilización de antibióticos específicos contra este microorganismo atípico.

Introduction. Mycoplasma pneumoniae may be involved in refractory asthma exacerbation. Objective. To determine the prevalence of Mycoplasma pneumoniae infection in patients with acute asthma exacerbation. Material and method. A prospective, crosssectional, observational, case-control study was carried out in patients older than 2 years old and younger than 12. Immunoglobulin M (IgM) antibodies were serologically determined for M. pneumoniae, using the NovaLisa® NovaTec kit for enzyme-linked immunosorbent assay (ELISA). Test results ≥ 11 NTU (NovaTec units) were regarded as positive. The statistical analysis was performed by means of the analysis of variance (ANOVA) and the χ² test, with a significance level of p < 0.05. Results. One hundred and eighty children were studied, of which 130 had asthma and 50 comprised the control group. Specific IgM was positive for 60 patients, that is 46.15% of the asthmatic children (p < 0.001). The severity of the exacerbation was directly related to IgM levels (p < 0.001). Hospitalization rate was 75%, and it was significantly associated to specific IgM levels (p < 0.001). Conclusion. Our data suggest that children with acute asthma show a high prevalence (46%) of Mycoplasma pneumoniae infection and that there is a close relation between severe acute asthma exacerbation and the presence of Mycoplasma pneumoniae infection. These findings might result in therapeutic implications centered in the use of specific antibiotics to fight this atypical organism.