Effect of glucocorticoid therapy on long-term growth and development of children with bronchiolitis / 中国当代儿科杂志

OBJECTIVES@#To explore the effect of glucocorticoid therapy on the growth and development of children with bronchiolitis.@*METHODS@#A total of 143 children with bronchiolitis who were treated with glucocorticoids from February 2017 to March 2018 were enrolled. The medical data were retrospectively collected, including height, weight, course of the disease, and diagnosis and treatment plan at initial admission. After three years of treatment, physical development indices were measured, growth and development were evaluated by Z-score, and related hematological parameters were measured, including osteocalcin, serum phosphorus, and insulin-like growth factor-1.@*RESULTS@#As for the children with bronchiolitis, the incidence rates of growth retardation and obesity increased significantly after three years of glucocorticoid therapy (P<0.05). The children treated with glucocorticoids for ≥29 days showed a significantly higher incidence rate of obesity than those treated with glucocorticoids for <29 days (P<0.05), while nebulized glucocorticoid treatment had no effect on the growth and development (P>0.05). Compared with the children with growth retardation, the children with normal development had significantly higher levels of serum phosphorus and insulin-like growth factor-1 (P<0.05).@*CONCLUSIONS@#Glucocorticoid therapy can adversely affect long-term growth and development in children with bronchiolitis.

Actualización de la bronquiolitis aguda / Acute bronchiolitis update

La bronquiolitis aguda es una condición respiratoria frecuente en los niños menores de 2 años. Representa la principal causa de hospitalización infantil y se caracteriza por la presencia de sibilancias asociada a signos de una infección respiratoria alta. El agente etiológico más común es el virus respiratorio sincicial. Existe una falta de consenso con respecto a su definición clínica; y por ello, su tratamiento varía en todo el mundo. El diagnóstico es clínico, sin necesidad de emplear laboratorio o imágenes en forma rutinaria. Diversas revisiones han demostrado que los broncodilatadores, adrenalina, corticoides y antibióticos, entre otros, carecen de eficacia por lo que no se sugiere su empleo. El tratamiento sigue siendo de soporte, mediante la administración de oxígeno y manteniendo una adecuada hidratación. Cuando no se logra disminuir el trabajo respiratorio o corregir la hipoxemia se puede utilizar la presión positiva en la vía aérea para prevenir y controlar la insuficiencia respiratoria. Este artículo desarrolla una breve revisión de las principales características clínicas, epidemiológicas, radiológicas, así como algunos de los diferentes tratamientos publicados en las últimas dos décadas.

Acute bronchiolitis is a common respiratory condition in children under 2 years old. It represents the main cause of childhood hospitalization characterized by the presence of wheezing associated with signs of an upper respiratory infection. The most common etiologic agent is respiratory syncytial virus. There is a lack of consensus regarding its clinical definition; and therefore, its treatment varies around the world. Diagnosis is clinical, without the need for routine laboratory or imaging. Various reviews have shown that bronchodilators, epinephrine, corticosteroids, and antibiotics, among others, lack efficacy, so their use is not suggested. Treatment continues to be supportive, by administering oxygen and maintaining adequate hydration. When it is not possible to reduce the work of breathing or correct the hypoxemia, positive airway pressure can be used to prevent and control respiratory failure. This article develops a brief review of the main clinical, epidemiological, and radiological characteristics, as well as some of the different treatments published in the last two decades.

A azitromicina administrada para bronquiolite aguda pode ter um efeito de proteção na sibilância recorrente / Azithromycin administered for acute bronchiolitis may have a protective effect on subsequent wheezing

RESUMO Objetivo Uma proporção significativa de lactentes desenvolve sibilância recorrente após um evento de bronquiolite aguda (BA). Estudos recentes demonstraram proteção para sibilância recorrente e menor morbidade respiratória em lactentes tratados com azitromicina durante uma crise de sibilância. O objetivo do presente estudo foi testar a hipótese de que a administração de azitromicina durante um evento BA reduz sibilos e reinternações hospitalares subsequentes. Métodos Trata-se de uma análise secundária de um estudo randomizado, duplo-cego, controlado por placebo, incluindo dados não publicados de sibilância e hospitalizações durante os seis meses iniciais após a internação por bronquiolite aguda. O estudo foi realizado em um hospital universitário terciário. Os bebês (<12 meses de idade) hospitalizados com BA foram randomizados para receber azitromicina ou placebo, administrados por via oral, por sete dias. As famílias foram contatadas por telefone aos três e seis meses após o evento agudo inicial, e responderam a um questionário padronizado para identificar sibilos recorrentes e reinternações hospitalares. Resultados Cento e quatro pacientes foram incluídos (grupo Azitromicina, n=50; grupo Placebo, n=54). Considerando o total de pacientes contatados com sucesso três meses após a hospitalização (n=70), a taxa de recorrência de sibilância no grupo da azitromicina foi significativamente menor do que no grupo placebo (RR=0,48; CI=0,24-0.98; p=0,038). Conclusões A azitromicina reduziu significativamente o risco de sibilância subsequente entre zero e três meses após a admissão hospitalar por bronquiolite aguda.

ABSTRACT Objective A significant proportion of the infants developed recurrent wheezing after an acute bronchiolitis (AB) event. Recent studies have demonstrated protection for recurrent wheeze and lower respiratory morbidity in infants treated with azithromycin during an acute respiratory wheezing. The aim of the present study was to test the hypothesis that administration of azithromycin during an AB event reduces subsequent wheezing and hospital re-admissions. Methods This is a secondary analysis of a randomized, double-blinded, placebo-controlled trial, including unpublished data of wheezing and hospitalizations during the initial 6 months following admission for acute viral bronchiolitis. The study was performed in a tertiary University hospital. Infants (<12 months of age) hospitalized with AB were randomized to receive either azithromycin or placebo, administered orally, for 7 days. Families were contacted by telephone at 3 and 6 months after the initial acute event and answered to a standardized questionnaire in order to identify recurrent wheezing and hospital readmissions. Results One hundred and four patients were included (Azithromycin group, n= 50; placebo group, n=54). Considering the total of patients contacted 3 months after hospitalization (n=70), the recurrence rate of wheezing in the azithromycin group was significantly lower than in the placebo group (RR = 0.48; CI = 0.24-0.98; p = 0.038). Conclusion Azithromycin significantly reduces the risk of subsequent wheezing between 0 and 3 months after hospital admission due to acute bronchiolitis irrespective of the presence of respiratory syncytial virus.

Temporal trend of hospitalizations for acute bronchiolitis in infants under one year of age in brazil between 2008 and 2015 / Tendência temporal das hospitalizações por bronquiolite aguda em lactentes menores de um ano no brasil entre 2008 e 2015

ABSTRACT Objective: To evaluate the trend of hospitalization for acute bronchiolitis in infants under one year of age, in the past eight years and after the implementation of the palivizumab immunization program in Brazil. Methods: The study is a retrospective analysis of data on infants younger than one year of age, who were hospitalized with acute bronchiolitis between 2008 and 2015 in Brazil. The Brazilian National Health System database was used. The rates of hospitalization in the pre-implementation (2008-2012) and post-implementation (2014-2015) periods of the palivizumab immunization program were evaluated. The total number of admissions in the same period was used as a comparison. Results: Between January 2008 and December 2015, 263,679 hospitalizations for bronchiolitis were recorded in infants younger than one year of age, 60% represented by boys. The incidence of hospitalization for bronchiolitis increased by 49% over this period (8.5 to 12.7 per 1,000 inhabitants per year). Between 2013 and 2014, the incidence rate of hospitalization for acute bronchiolitis decreased by 8% (12.5 to 11.5 per 1,000 inhabitants per year). However, in the second year of the program, hospitalization rate increased again by 10% (12.7 per 1,000 inhabitants per years). Conclusions: Acute bronchiolitis presented increasing rates of hospitalization over the study period. Hospitalization incidence for acute bronchiolitis declined one year after the implementation of palivizumab but increased again in the second year of the program.

RESUMO Objetivo: Avaliar a tendência de hospitalização por bronquiolite aguda (BA) em lactentes menores de um ano de idade nos últimos oito anos no Brasil e, secundariamente, após a implementação do programa de imunização por palivizumabe. Métodos: Análise retrospectiva dos dados de lactentes menores de um ano de idade, hospitalizados com diagnóstico de BA entre 2008 e 2015 no Brasil, utilizando o banco de dados do Sistema Único de Saúde (SUS). Foram avaliadas as taxas de hospitalização nos períodos pré-implementação (2008-2012) e pós-implementação (2014-2015) do programa de imunização por palivizumabe. O número total de internações no mesmo período foi utilizado como comparação. Resultados: Entre janeiro de 2008 e dezembro 2015 foram registradas 263.679 internações por bronquiolite em lactentes menores de um ano de idade, 60% representado por meninos. A incidência de hospitalização por bronquiolite aumentou em 49% ao longo desse período (8,5 para 12,7 por mil ­habitantes/­ano). Entre 2013 e 2014, a taxa de incidência de hospitalização por BA diminuiu 8% (12,5 para 11,5 por mil habitantes/ano). Porém, no segundo ano do programa, a taxa de internação aumentou novamente em 10% (12,7 por mil habitantes/ano). Conclusões: A BA apresentou taxas de hospitalização crescente ao longo do período estudado. A incidência de hospitalizações de BA apresentou declínio um ano após a implementação de palivizumabe e retornou à tendência crescente no segundo ano do programa.

Beta-2 agonistas para el tratamiento de bronquiolitis / Beta-2 agonists for the treatment of bronchiolitis

INTRODUCCIÓN La bronquiolitis es la inflamación aguda de las vías aéreas de pequeño calibre, teniendo como causa principal las infecciones virales. Es altamente frecuente en menores de dos años, sobretodo en menores de 12 meses. Existe gran controversia sobre el manejo de esta patología, siendo especialmente cuestionable el uso de beta-2 agonistas de corta acción tanto en el ámbito ambulatorio como hospitalario. MÉTODOS Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud a nivel mundial, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis, y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES Identificamos siete revisiones sistemáticas que en conjunto incluyen 47 estudios primarios, de los cuales 44 corresponden a ensayos aleatorizados. Concluimos que el uso de beta-2 agonistas podría no tener ningún beneficio en el manejo de la bronquiolitis, en términos de necesidad de hospitalización y/o duración de la misma. Por otra parte, podría aumentar efectos adversos como arritmias, sin embargo, la certeza de esta evidencia es baja

Broncodilatadores en pacientes con bronquiolitis / Bronchodilators for bronchiolitis

La bronquiolitis es una infección respiratoria aguda baja de causa viral, de aparición invernal, que es común en bebés de 0a 12 meses de edad. Conduce a que las vías respiratorias pequeñas se inflamen y se llenen de desechos, obstruyéndose.El bebé tiene una tos fuerte, secreción nasal, generalmente fiebre y puede presentar sibilancias dificultad respiratoria ydesaturación de oxígeno. Tras la presentación de un caso en la guardia se generó una controversia científica sobre lautilidad de los broncodilatadores en pacientes con bronquiolitis. Luego de realizar una búsqueda bibliográfica y seleccionarla evidencia más reciente y de mejor calidad, se concluye que la evidencia no apoya el uso de broncodilatadores enpacientes con bronquiolitis.(AU)

Bronchiolitis is a low acute respiratory lower respiratory tract infection of viral origin, winter appearance, which is commonin babies from 0 to 12 months of age. It causes the small airways in the lungs to become inflamed and fill with debris. Theinfant has a harsh cough, runny nose, usually fever and may have wheezing, respiratory distress and oxygen desaturation.After the presentation of a case in the emergency department, a scientific controversy was generated about the usefulnessof bronchodilators in patients with bronchiolitis. After conducting a literature search and selecting the most recent and bestquality evidence, it is concluded that evidence does not support the use of bronchodilators in patients with bronchioliTIS.(AU)

Uso de cánula de alto flujo en niños menores de 24 meses en salones de pediatría / Use of high flow nasal cannula in infants younger than 24 months in general pediatric rooms

Resumen Justificación y objetivo: la patología respiratoria más frecuente y la principal causa de hospitalización en niños menores de 2 años en Costa Rica y el mundo, es la bronquiolitis. La terapia no invasiva de alto flujo se introdujo en Costa Rica en 2008. El objetivo de este trabajo fue demostrar la utilidad de la cánula de alto flujo en niños menores de 2 años con patología respiratoria. Métodos: estudio transversal observacional en pacientes menores de 2 años que requirieron la colocación de cánula de alto flujo, de julio a octubre de 2015, en el Hospital Nacional de Niños. Resultados: se realizó un análisis de 63 pacientes, con una media de edad de 10 meses y un peso promedio de 8,6 kg. El principal diagnóstico fue bronquiolitis y el germen más común fue metaneumovirus. Se demostró una mejoría estadísticamente significativa en la saturación de oxígeno y el puntaje, luego de la colocación de la cánula de alto flujo (p < 0,05), y disminución de la frecuencia respiratoria (p 0,016) entre los que no requirieron ventilación mecánica asistida, con un valor de siquiera un 30 % menos de la inicial. Hasta un 95 % de los pacientes con una saturación de oxígeno inicial menor al 87 %, ameritó la colocación de ventilación mecánica asistida. La duración promedio de terapia fue de 2 días. De los pacientes estudiados, 16 (25 %) llegaron a requerir ventilación mecánica asistida. Conclusiones: en el grupo analizado, la cánula de alto flujo demostró mejoría en los parámetros clínicos. Los pacientes que ameritaron ventilación mecánica asistida fueron aquellos en donde la mejoría en el puntaje de gravedad fue menor o igual a 2 puntos, o no hubo disminución en la frecuencia respiratoria de al menos un 30 %, y la saturación de oxígeno inicial fue menor al 87 %.

Abstract Background and aim: Bronquiolitis remains the most common respiratory etiology that affects children under 2 years of age, and the most common cause of hospitalization in this age group. Non-invasive technology with high flow nasal cannula was first introduced in Costa Rica in 2008; the main goal of the study was to demonstrate the utility of this cannula in children under 2 years of age with respiratory disease. Methodology: Transversal observational study, in children under 2 years of age that required high flow nasal cannula therapy, from July to October 2015 in Costa Rica's main hospital, Hospital Nacional de Niños. Results: a final simple of 63 patients was obtained. The majority came from the central area of the country, with an average age of 10 months and an average weight of 8,6 kg. The main diagnosis was bronquiolitis. The most commonly virus found was the Metaneumovirus. There was a significant improve in the oxygen saturation with the device (p < 0,05) and a significant reduction in respiratory rates (p 0,016) between the children that did not required intubation of at least 30% from the initial value. Up to 95% of the patients with initial oxygen saturation less tan 87% required mechanical ventilation. The average duration of the therapy was of two days. 16 patients (25%) required mechanical ventilation. Conclusions: In Costa Rica, the high flow nasal cannula therapy works and improves clinical parameters. The patients that required intubation were those in which the improvement of the severity scale was of 2 or less points, was no reduction in respiratory rates of at least 30% and the initial oxygen saturation was less than 87%.

¿Tienen los corticoides inhalatorios un rol en la bronquiolitis? / Do inhaled corticosteroids have a role for bronchiolitis?

INTRODUCCIÓN: La bronquiolitis corresponde a una inflamación aguda de las vías aéreas pequeñas secundaria a infección viral y es una patología frecuente en menores de dos años. Se ha propuesto que el uso de corticoides inhalatorios durante una bronquiolitis podría reducir la recurrencia de sibilancias o el desarrollo de asma, sin embargo, existe controversia al respecto. MÉTODOS: Para responder a esta interrogante utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos tres revisiones sistemáticas que en conjunto incluyen 11 ensayos aleatorizados. Concluimos que el uso de corticoides inhalatorios no reduce la recurrencia de sibilancias o asma en pacientes con bronquiolitis.

INTRODUCTION: Bronchiolitis consists of an acute small airways inflammation secondary to a viral infection and is a frequent pathology among children under 2 years. The use of inhaled corticosteroids during bronchiolitis has been proposed to reduce recurrent wheeze or asthma, however there is controversy about it. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified three systematic reviews including 11 randomized trials. We concluded that inhaled corticosteroids do not reduce recurrent wheeze or asthma in patients with bronchiolitis.

¿Deben utilizarse corticoides sistémicos en la bronquiolitis? / Should systemic corticosteroids be used for bronchiolitis?

INTRODUCCIÓN: La bronquiolitis es una inflamación aguda de las vías aéreas pequeñas debida principalmente a una infección viral. Es una patología frecuente en menores de dos años y en especial en menores de 12 meses. Se ha propuesto el uso de corticoides sistémicos en bronquiolitis, en especial en pacientes de mayor severidad, siendo controversial su utilidad. MÉTODOS: Para evaluarlo utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cuatro revisiones sistemáticas que en conjunto incluyeron 20 ensayos aleatorizados. Concluimos que el uso de corticoides sistémicos no aporta ningún beneficio en el tratamiento de la bronquiolitis, aún en pacientes con ventilación mecánica.

INTRODUCTION: Bronchiolitis is an acute small airways inflammation mainly caused by a viral infection. It is frequent in children under two years of age, particularly under 12 months. The use of systemic corticosteroids has been proposed for bronchiolitis, especially for severely ill patients. However, its efficacy is still controversial. METHODS: To answer this question we gathered information using Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data from primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified four systematic reviews, including 20 randomized trials overall. We concluded the use of systemic corticosteroids has no benefit for the treatment of bronchiolitis, even for patients with mechanical ventilation.

Uso de macrolídeos em doenças pulmonares: controvérsias da literatura recente / Use of macrolides in lung diseases: recent literature controversies

Resumo Objetivo: Revisar os mecanismos de ação de macrolídeos em doenças respiratórias pediátricas e as suas indicações clínicas. Fonte de dados: Revisão na base de dados Pubmed, compreendendo os termos em inglês referentes ao tema básico. Síntese dos dados: O seu espectro de ação estende-se desde a produção de mediadores inflamatórios até o controle da hipersecreção de muco e a modulação de mecanismos de defesa do hospedeiro. O potencial benefício dos antibióticos macrolídeos foi estudado em doenças pulmonares como a fibrose cística, as bronquiectasias, a asma, a bronquiolite aguda e as bronquiectasias não ligadas à fibrose cística. Diversos estudos avaliaram os benefícios dos macrolídeos na asma resistente a terapia, porém os resultados são controversos e as indicações devem ser limitadas a fenótipos específicos. Na bronquiolite viral não há benefícios consistentes nos quadros agudos, embora dados recentes mostrem um efeito na prevenção de sibilância recorrente. Em pacientes com fibrose cística os resultados também são contraditórios, mas o consenso é de que há um pequeno benefício clínico, especialmente para os pacientes infectados por P. aeruginosa. Também não foi observada ação positiva dos macrolídeos em pacientes com bronquiolite obliterante pós-infecciosa. Crianças com bronquiectasias não relacionadas à fibrose cística parecem ter claros benefícios em relação ao uso de macrolídeos, os quais mostraram vantagens clínicas, de proteção ao parênquima e na função pulmonar. Conclusões: O uso em longo prazo de macrolídeos deve ser limitado a situações altamente selecionadas, especialmente em pacientes com bronquiectasias. Avaliação cuidadosa dos benefícios e potenciais danos são ferramentas para indicação em grupos específicos.

Abstract Objective: To review the mechanisms of action of macrolides in pediatric respiratory diseases and their clinical indications. Sources: Review in the PubMed database, comprising the following terms in English: “macrolide and asthma”; “macrolide and cystic fibrosis”; “macrolide bronchiolitis and viral acute”; “macrolide and bronchiolitis obliterans”; and “macrolide and non-CF bronchiectasis”. Summary of the findings: The spectrum of action of macrolides includes production of inflammatory mediators, control of mucus hypersecretion, and modulation of host-defense mechanisms. The potential benefit of macrolide antibiotics has been studied in a variety of lung diseases, such as cystic fibrosis (CF), bronchiectasis, asthma, acute bronchiolitis, and non-CF bronchiectasis. Several studies have evaluated the benefits of macrolides in asthma refractory to therapy, but the results are controversial and indications should be limited to specific phenotypes. In viral bronchiolitis, there is no consistent benefit in acute conditions, although recent data have shown an effect in recurrent wheezing prevention. In patients with CF results are also contradictory, but the consensus states there is a small clinical benefit, especially for patients infected with P. aeruginosa. There was also no positive action of macrolides in patients with post-infectious bronchiolitis obliterans. Children with non-CF bronchiectasis seem to have clear benefits regarding the use of macrolides, which showed clinical advantages in parenchyma protection and lung function. Conclusions: The long-term use of macrolides should be limited to highly selected situations, especially in patients with bronchiectasis. Careful evaluation of the benefits and potential damage are tools for their indication in specific groups.

Bronchiolitis; role of oral salbutamol administration for providing symptomatic relief in children

To determine the efficacy of oral salbutamol administration for symptomatic relief in children less than two years of age with acute mild bronchiolitis. Interventional study. Outpatient department of Department of Pediatrics, independent university hospital, Faisalabad, Pakistan, from October 2010 to March 2011. 160 children less than two years of age diagnosed clinically as acute mild bronchiolitis with comparable baseline parameters [age, weight, duration of present illness] were included in the study. They were randomly placed in two groups, Salbutamol Group [SG] [n=80] Placebo Group [PG] [n =80] and were followed daily for first 3 days, then on day 5 and day 7 in outpatient department. Oral salbutamol was administered [0.1 mg/kg/dose] three times daily for 7 days or till complete resolution of illness, whichever came earlier. Time for resolution of illness [ROI] was primary outcome variable whereas time for resolution of cough, coryza, breathlessness, wheeze, achievement of normal feeding and sleep patterns and salbutamol adverse effects were secondary outcome variables. Mean duration of resolution of illness [ROI] was similar in both groups. [6.1 +/- 0.75] days in the salbutamol group and [6.0 +/- 0.80] days in placebo group [p=0.53]. There was no significant resolution time difference of secondary outcome variables between the two study groups. Cough [SG 4.1[0.70, PG 4.1]0.68, P=0.68] Coryza [SG 4.3[ 0.59, PG 4.2] 0.62, P=0.14] Wheeze and Breathlessness [SG 3.8[0.60, PG 3.8]0.63, p=0.24] Sleep [SG 4.5[0.40, PG 4.4]0.55, p=0.19] Feeding [SG 4.3[0.59, PG 4.2]0.62, P= 0.14]. Salbutamol adverse effects [tremors, irritability] were observed in 13 [16.25%] children in salbutamol group. Oral salbutamol administration is not superior to placebo in providing symptomatic relief in children with acute mild bronchiolitis

Manejo e diagnóstico do lactente sibilante em atendimentos de emergência / Management and diagnosis of the wheezing infant in emergency care

A sibilância é um sinal de alerta fundamental nas crianças nos primeiros anos de vida. Diversas doenças estão entre as causas desse estado sendo que asma e infecções virais são as mais comuns. O diagnóstico precoce aliado a um correto tratamento e manejo das crises são necessários à boa saúde do lactente.

Wheezing is a warning sign in the first years of life. Various diseases are among the causes of this state, and asthma and viral infections are the most common causes. Early diagnosis combined with a correct treatment and management of the exacerbations are necessary for infant health.

Efeito anti-inflamatório dos macrolídeos em doenças pulmonares da infância / Anti-inflammatory effects of macrolides in childhood lung diseases

Os macrolídeos são fármacos com efeitos antimicrobianos especialmente contra patógenos intracelulares. Vários estudos têm demonstrado possíveis efeitos anti-inflamatórios dos macrolídeos. Esses medicamentos inibem a produção de algumas interleucinas e podem reduzir a inflamação neutrofílica pulmonar. Ensaios clínicos têm demonstrado efeitos benéficos dos macrolídeos em diversas doenças pulmonares crônicas. O objetivo deste estudo foi revisar os dados recentes da literatura médica sobre os efeitos anti-inflamatórios dos macrolídeos nas doenças respiratórias da infância, através da pesquisa da base de dados Medline (PubMed) dos seguintes termos em inglês: "macrolide and cystic fibrosis"; "macrolide and asthma"; "macrolide and bronchiolitis obliterans"; e "macrolide and acute bronchiolitis" Foram selecionados artigos publicados em revistas científicas internacionais entre 2001 e 2012. Estudos clínicos e evidências in vitro comprovam o efeito anti-inflamatório dos macrolídeos em doenças respiratórias. Alguns ensaios clínicos demonstram benefícios na administração de macrolídeos em pacientes com fibrose cística; porém, o risco de resistência bacteriana deve ser considerado na análise desses benefícios. Tais benefícios são controversos em outras doenças respiratórias, e seu uso rotineiro não está indicado. Mais estudos clínicos controlados são necessários para avaliar a eficácia desses medicamentos como anti-inflamatórios. Dessa forma, poderemos definir melhor os benefícios dos macrolídeos no tratamento de cada uma das situações clínicas especificadas.

Macrolides are drugs that have antimicrobial effects, especially against intracellular pathogens. Various studies have shown that macrolides might also have anti-inflammatory effects. Macrolides inhibit the production of interleukins and can reduce pulmonary neutrophilic inflammation. Clinical trials have demonstrated beneficial effects of macrolides in various chronic lung diseases. The objective of this study was to review recent data in the medical literature on the anti-inflammatory effects of macrolides in childhood lung diseases by searching the Medline (PubMed) database. We used the following search terms: "macrolide and cystic fibrosis"; "macrolide and asthma"; "macrolide and bronchiolitis obliterans"; and "macrolide and acute bronchiolitis". We selected articles published in international scientific journals between 2001 and 2012. Clinical studies and in vitro evidence have confirmed the anti-inflammatory effect of macrolides in respiratory diseases. Some clinical trials have shown the benefits of the administration of macrolides in patients with cystic fibrosis, although the risk of bacterial resistance should be considered in the analysis of those benefits. Such benefits are controversial in other respiratory diseases, and the routine use of macrolides is not recommended. Further controlled clinical trials are required in order to assess the efficacy of macrolides as anti-inflammatory drugs, so that the benefits in the treatment of each specific clinical condition can be better established.

Uso de dexametasona y salbutamol nebulizados en bronquiolitis aguda: estudio clínico comparativo / Comparative clinical study of dexamethasone vs. nebulized salbutamol in acute bronchiolitis

Objetivo: Evaluar la eficacia de salbutamol y dexametasona nebulizados comparados con salbutamol solo en pacientes con bronquiolitis aguda. Material y métodos: Estudio clínico controlado, aleatorizado, en pacientes de 1 a 18 meses de edad con diagnóstico de bronquiolitis aguda y evolución menor de tres días. Se asignaron dos grupos: 1) salbutamol (n = 24) o 2) salbutamol más dexametasona (n = 25) administrado por micronebulizaciones cada cuatro horas por 24 horas. Se midieron las frecuencias cardiaca y respiratoria, la gravedad del cuadro mediante el Respiratory Distress Assigment Index, el Silvermann-Andersen, saturación de O2 y tiempo de desaparición de la dificultad respiratoria y frecuencia de altas en 24 horas. Resultados: No se encontraron diferencias significativas entre los grupos de estudio, excepto en la frecuencia de altas hospitalarias en las primeras 24 horas, 75 vs 96 % p < 0.04 respectivamente. Conclusiones: La aplicación de salbutamol más dexametasona es más rápida para controlar la dificultad respiratoria en niños con bronquiolitis aguda en comparación con la aplicación de salbutamol solo.

OBJECTIVE: Asess the efficacy of nebulized salbutamol and dexamethasone compared with nebulized salbutamol, in patients with bronchiolitis. MATERIAL AND METHODS: A blinded clinical trial was performed with 49 patients between 1-18 months diagnosed with bronchiolitis with three days or less of disease evolution. Participant's parents signed an informed consent and patients did not receive prior medication. Patients were randomly assigned to two groups: nebulized salbutamol or salbutamol plus dexamethasone, which they received every four hours during twenty-four hours. We measured heart and respiratory rate; respiratory distress index, oxygen saturation, and Silverman Andersen scores. RESULTS: No significant differences were found between groups for treatment response; but the frequency of hospital release at 24 hrs was significant among groups; 75 vs 96 % respectively (p = 0.04). CONCLUSIONS: The administration of salbutamol plus dexamethasone is more effective in the control of respiratory distress in children with bronchiolitis compared with the use of salbutamol alone.

Segurança de nebulização com 3 a 5 ml de adrenalina (1:1000) em crianças: uma revisão baseada em evidência / The safety of nebulization with 3 to 5 ml of adrenaline (1:1000) in children: an evidence based review

OBJETIVO: Apresentar evidências sobre a segurança da nebulização com 3 a 5 ml de adrenalina (1:1000) no tratamento das crianças com obstrução inflamatória aguda das vias aéreas. FONTES DE DADOS: Uma busca eletrônica foi feita, utilizando-se, principalmente, o banco de dados do MEDLINE (janeiro de 1949 a julho de 2004). Os critérios de inclusão do estudo para esta revisão foram: 1) ensaio clínico randomizado; 2) pacientes (até 12 anos) com diagnós tico de bronquiolite ou laringotraqueobronquite; 3) uso de adrenalina (1:1000) através de nebulização. Os principais dados extraídos dos ensaios dizem respeito a doses de adrenalina e seus efeitos sobre a freqüência cardíaca e a pressão arterial sistêmica, bem como outros efeitos colaterais. SíNTESE DOS DADOS: Sete ensaios clínicos, com um total de 238 pacientes, foram incluídos para esta revisão. Dos cinco ensaios clínicos nos quais a maior dose (> 3 ml) de adrenalina foi usada, dois demonstraram aumento significativo de freqüência cardíaca. O aumento médio de freqüência cardíaca variou de sete a 21 batimentos por minuto, até 60 minutos após o tratamento. A maior incidência de palidez foi observada em um ensaio clínico com 21 crianças tratadas com 3 ml de adrenalina através de nebulização (47,6 por cento no grupo de adrenalina versus 14,3 por cento no grupo de salbutamol, 30 minutos após o tratamento). Não foram observados, em dois ensaios clínicos, efeitos significativos em nebulização com adrenalina (4 e 5 ml) na pressão arterial sistêmica. CONCLUSAO: As evidências mostram que nebulização com 3 a 5 ml de adrenalina (1:1000) é uma terapia segura, com poucos efeitos colaterais, em crianças com obstrução inflamatória aguda das vias aéreas.

Some clinico-epidemiological aspect of bronchiolitis among infants and young children--a hospital based study.

A hospital based prospective study was carried out from 1st October 1998 to 30th September 1999 on children with clinical diagnosis of bronchiolitis in OPD and indoor patients of the Department of Paediatric Medicine, Medical College Kolkata. The objective of the study was to find out the proportional case rate and clinico epidemiological features of the disease. The effectiveness of nebulized salbutamol among bronchiolitis children was also looked into. The proportional case rate was found to be 4.65%. Low birth weight (LBW)/premature babies (51.11%) malnutrition (40%), nonimmunization (55.55%) & non breastfeeding practices (48.88%) were significant risk factors for severe bronchiolitis. Response to nebulized salbutamol was remarkably higher (70%) in 6m to 12m age group.