Can myofunctional therapy increase tongue tone and reduce symptoms in children with sleep-disordered breathing?

PURPOSE: Data in the literature suggest that myofunctional therapy (MT) may be able to play a role in the treatment of children with sleep-disordered breathing (SDB). Our study investigated the effectiveness of MT in reducing respiratory symptoms in children with SDB by modifying tongue tone. METHODS: Polysomnographic recordings were performed at baseline to assess obstructive sleep apnea (OSA) severity in 54 children (mean age 7.1 ± 2.5 years, 29 male) with SDB. Patients were randomly assigned to either the MT or no-MT group. Myofunctional evaluation tests, an assessment of tongue strength, tongue peak pressure, and endurance using the Iowa Oral Performance Instrument (IOPI), and nocturnal pulse oximetry were performed before (T0) and after (T1) 2 months of treatment. RESULTS: MT reduced oral breathing (83.3 vs 16.6%, p < 0.0002) and lip hypotonia (78 vs 33.3%, p < 0.003), restored normal tongue resting position (5.6 vs 33.4%, p < 0.04), and significantly increased mean tongue strength (31.9 ± 10.8 vs 38.8 ± 8.3, p = 0.000), tongue peak pressure (34.2 ± 10.2 vs 38.1 ± 7.0, p = 0.000), and endurance (28.1 ± 8.9 vs 33.1 ± 8.7, p = 0.01) in children with SDB. Moreover, mean oxygen saturation increased (96.4 ± 0.6 vs 97.4 ± 0.7, p = 0.000) and the oxygen desaturation index decreased (5.9 ± 2.3 vs 3.6 ± 1.8, p = 0.001) after MT. CONCLUSIONS: Oropharyngeal exercises appear to effectively modify tongue tone, reduce SDB symptoms and oral breathing, and increase oxygen saturation, and may thus play a role in the treatment of SDB.

Oropharyngeal exercises to reduce symptoms of OSA after AT.

PURPOSE: This study evaluated the efficacy of oropharyngeal exercises in children with symptoms of obstructive sleep apnea syndrome (OSA) after adenotonsillectomy. METHODS: Polysomnographic recordings were performed before adenotonsillectomy and 6 months after surgery. Patients with residual OSA (apnea-Hypopnea Index, AHI > 1 and persistence of respiratory symptoms) after adenotonsillectomy were randomized either to a group treated with oropharyngeal exercises (group 1) or to a control group (group 2). A morphofunctional evaluation with Glatzel and Rosenthal tests was performed before and after 2 months of exercises. All the subjects were re-evaluated after exercise through polysomnography and clinical evaluation. The improvement in OSA was defined by ΔAHI: (AHI at T1 - AHI at T2)/AHI at T1 × 100. RESULTS: Group 1 was composed of 14 subjects (mean age, 6.01 ± 1.55) while group 2 was composed of 13 subjects (mean age, 5.76 ± 0.82). The AHI was 16.79 ± 9.34 before adenotonsillectomy and 4.72 ± 3.04 after surgery (p < 0.001). The ΔAHI was significantly higher in group 1 (58.01 %; range from 40.51 to 75.51 %) than in group 2 (6.96 %; range from -23.04 to 36.96 %). Morphofunctional evaluation demonstrated a reduction in oral breathing (p = 0.002), positive Glatzel test (p < 0.05), positive Rosenthal test (p < 0.05), and increased labial seal (p < 0.001), and lip tone (p < 0.05). CONCLUSIONS: Oropharyngeal exercises may be considered as complementary therapy to adenotonsillectomy to effectively treat pediatric OSA.

Does a parent-reported history of pneumonia increase the likelihood of respiratory symptoms needing therapy in asthmatic children and adolescents?

BACKGROUND: Asthmatic children and adolescents attending outpatient clinics often have a history of pneumonia. Whether respiratory symptoms, lung function, and airway inflammation differ in asthmatic patients with and without a history of pneumonia remains controversial. AIMS: To compare clinical, lung functional, and inflammatory variables in asthmatic outpatients with and without a history of pneumonia. Methods. In 190 asthmatic outpatients, aged 6-18 years, we assessed respiratory symptoms, lung function (flows, volumes, and pulmonary diffusion capacity, DLCO/VA), and atopic-airway inflammation as measured by the fractional concentration of exhaled nitric oxide (FE(NO)). A previous medical and radiological diagnosis of pneumonia was defined as "recurrent pneumonia" if subjects had at least three pneumonia episodes or two episodes within a year. RESULTS: Of the 190 outpatients studied, 38 (20%) had a history of pneumonia. These patients had more frequent upper-respiratory symptoms, nighttime awakenings in the past 4 weeks, daily use of inhaled corticosteroids, and lower FE(NO) than the 152 asthmatic children without previous pneumonia (FE(NO): 20.6 ppb, 95% CI: 15.2-28.0 vs. 31.1 ppb, 95% CI: 27.0-35.8; p < .05). Of the 38 patients with previous pneumonia, 14 had recurrent pneumonia. Despite comparable lung volumes and flows, they also had lower DLCO/VA than asthmatic children with no recurrent pneumonia and asthmatic children without previous pneumonia (DLCO/VA%: 91.2 ± 11.3 vs. 108.5 ± 14.7 vs. 97.9 ± 18.6, p < .05). CONCLUSION: Respiratory assessment in asthmatic children and adolescents with a history of pneumonia, especially recurrent pneumonia, often discloses symptoms needing corticosteroid therapy, and despite normal lung volumes and flows, mild reductions in the variables reflecting gas diffusion and atopic-airway inflammation (DLCO/VA and FE(NO)). Whether these respiratory abnormalities persist in adulthood remains an open question.

8-Isoprostane in exhaled breath condensate and exercise-induced bronchoconstriction in asthmatic children and adolescents.

BACKGROUND: Exercise-induced bronchoconstriction (EIB) in the asthmatic child is associated with persistent airway inflammation and poor disease control. EIB could arise partly from airway oxidative stress. Exhaled breath condensate (EBC) levels of 8-isoprostane (IsoP), which is a known marker of oxidative stress, might therefore be helpful for monitoring asthma noninvasively. METHODS: We recruited 46 asthmatic children and adolescents 6 to 17 years of age (29 boys), all of whom underwent lung function testing, measurement of the fractional concentration of exhaled nitric oxide (FENO), and collection of EBCs for 8-IsoP measurement before and after exercise challenge. FENO was measured before exercise and 5 min and 20 min after exercise. Spirometry was repeated 1, 5, 10, 15, and 20 min after exercise. RESULTS: Baseline 8-IsoP levels (but not baseline FENO levels) correlated with the fall in FEV(1) 5 min after exercise (r = - 0.47; p = 0.002). 8-IsoP levels measured after exercise remained unchanged from baseline levels; conversely, FENO levels decreased in parallel with the decline in FEV(1) at 5 min (r = 0.44; p = 0.002). The mean baseline 8-IsoP concentrations were higher in patients with EIB (n = 12) than in those without EIB (n = 34; 44.9 pg/mL [95% confidence interval (CI), 38.3 to 51.5] vs 32.3 pg/mL [95% CI, 27.6 to 37.0], respectively; p < 0.01). No difference was found in the mean baseline FENO between groups (with EIB group: 38.7 ppb; 95% CI, 24.5 to 61.1; without EIB group: 29.1 ppb; 95% CI, 22.0 to 38.4). CONCLUSIONS: Increased 8-IsoP concentrations in EBC samples of asthmatic children and adolescents with EIB suggest a role for oxidative stress in bronchial hyperreactivity.

Reduced exhaled nitric oxide in children after testing of maximal expiratory pressures.

Spirometry in adult subjects can induce a fall in concentration of exhaled nitric oxide (FE(NO)). Scarce information is available on the FE(NO) decrease after spirometry or after other forced lung-function maneuvers in children. We compared changes in FE(NO) induced by repeated spirometry and testing of maximal expiratory pressures (P(Emax)). Twenty-four sex- and age-matched children aged 9-18 years (mean age +/- SD, 13.3 +/- 2.8 years; 12 healthy, 12 asthmatic) were allocated to 1-week-apart sessions of repeated maneuvers of either forced vital capacity (FVC) or P(Emax). Baseline FE(NO) measurements were followed by FVC or P(Emax) maneuvers every 15 min for 45 min, whereas FE(NO) was measured at each step for 60 min. After repeated P(Emax) but not after FVC maneuvers, FE(NO) values decreased significantly from baseline in both groups. In healthy children, geometric mean FE(NO) (95% confidence intervals) decreased from 9.1 (7.0-11.8) ppb at baseline to 8.2 (6.3-10.6) ppb at 15 min and 7.7 (5.6-10.6) ppb at 30 min (P < 0.05 and P < 0.01, respectively), and remained unchanged at 45 and 60 min. In asthmatic children, FE(NO) levels fell from 21.6 (13.3-34.9) ppb at baseline to 15.1 (9.1-25.1) ppb at 15 min and remained low at 30, 45, and 60 min: 17.8 (10.7-29.5) ppb, 17.5 (10.2-30.1) ppb, and 17.6 (10.6-29.2) ppb, P < 0.01, for all differences from baseline. Repeated P(Emax) and FVC maneuvers increased FE(NO) variability, as compared with repeated FE(NO) measurements alone. Previous forced lung-function maneuvers may affect FE(NO) measurements in children. Although P(Emax) testing has a greater influence than spirometry on FE(NO) levels in children, both procedures should be avoided before measuring FE(NO).

Why Chlamydia pneumoniae is associated with asthma and other chronic conditions? Suggestions from a survey in unselected 9 yr old schoolchildren.

Despite numerous studies demonstrating an association between asthma and many other chronic conditions and signs of Chlamydia pneumoniae (Cp) infection, the role of Cp in the pathogenesis of these illness remain still unclear. We investigated the prevalence of Cp antigen in the upper airways and the prevalence of detectable Cp serum antibodies in an unselected population of 207 9-yr-old schoolchildren. We also sought the presence of asthma, chronic or recurrent respiratory symptoms by means of questionnaire completed by the parents. Nasal aspirate, blood sampling and allergen skin prick tests were also performed. None of the children had obvious signs of acute infection at physical examination. Cp DNA was detected in nasal aspirates from 20 of the 207 children tested and serum IgG antibodies for Cp in 68 children. No association was found between atopy or history of atopic illness and the presence of Cp DNA or antibody production. This finding is explained by the fact that our study was conducted in an unselected childhood population, inherently including few children with asthma. A strong association between the status of antigen carrier and the presence of detectable Cp serum immunoglobulin (Ig)G or IgM suggests that subjects with detectable Cp antibodies have an impaired ability to eliminate this pathogen when infected. Because Cp eradication requires a strong Th1 lymphocyte response, the previously proven association between Cp and asthma, might reflect the known association of asthma with Th2-oriented lymphocytic activity.

Additive effect of eosinophilia and atopy on exhaled nitric oxide levels in children with or without a history of respiratory symptoms.

Although atopy and blood eosinophilia both influence exhaled nitric oxide (eNO) measurements, no study has quantified their single or combined effect. We assessed the combined effect of atopy and blood eosinophilia on eNO in unselected schoolchildren. In 356 schoolchildren (boys/girls: 168/188) aged 9.0-11.5 yr, we determined eNO, total serum IgE, blood eosinophil counts and did skin prick tests (SPT) and spirometry. Parents completed a questionnaire on their children's current or past respiratory symptoms. Atopy was defined by a SPT >3 mm and eosinophilia by a blood cell count above the 80th percentile (>310 cells/ml). eNO levels were about twofold higher in atopic-eosinophilic subjects than in atopic subjects with low blood eosinophils [24.3 p.p.b. (parts per billion) vs. 14.1 p.p.b.] and than non-atopic subjects with high or low blood eosinophils (24.3 p.p.b. vs. 12.2 p.p.b. and 10.9 p.p.b.) (p <0.001 for both comparisons). The additive effect of atopy and high eosinophil count on eNO levels remained unchanged when subjects were analyzed separately by sex or by a positive history of wheeze (n=60), respiratory symptoms other than wheeze (n=107) or without respiratory symptoms (n=189). The frequency of sensitization to Dermatophagoides (Dpt or Dpf) was similar in atopic children with and without eosinophilia (66.2% and 67.4%, respectively); eosinophilia significantly increased eNO levels in Dp-sensitized children as well in children sensitized to other allergens. In a multiple linear regression analysis, eNO levels were mainly explained by the sum of positive SPT wheals and a high blood eosinophil count (t=4.8 and 4.3, p=0.000), but also by the presence of respiratory symptoms (especially wheeze) and male sex (t=2.6 and 2.0, p=0.009 and 0.045, respectively). Measuring eNO could be a simple, non-invasive method for identifying subjects at risk of asthma in unselected school populations.

Skin reactivity to histamine and codeine in unselected 9-year-old children from Italy, Poland and Libya.

BACKGROUND: Previous studies have shown that histamine skin reactivity (the dimensions of a skin wheal elicited by a prick with histamine 10 mg/ml) in unselected school children has increased in Italy during the past two decades and is higher in Italy than in Poland. Hence this variable can probably be influenced by a changing or different lifestyle. The aim of this study was to compare skin reactivity to histamine and codeine (a marker of histamine releasability from mast cells) in schoolchildren from countries with different lifestyles. METHODS: Six previously unstudied unselected populations of 9-year-old schoolchildren (two each from Poland, Italy, and Libya; n = 863 subjects; 49.0% males) were pricked with two concentrations of histamine (10 and 1 mg/ml) and codeine (90 and 9 mg/ml). RESULTS: The higher concentrations of both pharmacologic agents tested yielded significantly different wheal areas in the three countries: Poland < Italy < Libya (histamine, 11.8, 16.1 and 20.7 mm2; codeine, 9.2, 13.2 and 16.2 mm2; p < 0.001 for all comparisons). The lower concentrations elicited almost matching results. Histamine wheal areas correlated closely with areas elicited by codeine in the same individual: angular coefficients of the histamine to codeine regression lines were 0.535, Italy; 0.551, Libya; 0.612, Poland; and 0.581 for the whole population. More histamine was needed to produce a wheal in Poland than in Libya: a 20-mm2 wheal required an injected histamine concentration of about 8.8 mg/ml in Libya, 29.5 mg/ml in Italy and 102.1 mg/ml in Poland. CONCLUSION: More studies are necessary to explain the observed international differences in skin histamine reactivity and their effect on the prevalence of positive allergen skin tests.

Skin reactivity to histamine and to allergens in unselected 9-year-old children living in Poland and Italy.

Several studies have shown a higher prevalence of positive skin-prick tests to airborne allergens in Western than in Eastern European countries. We have recently reported that skin histamine reactivity significantly increased in Italy over the past 15 years. Population differences in skin histamine reactivity could, at least in part, explain the reported differences in positive allergen skin tests. To test this hypothesis we compared histamine skin reactivity and the prevalence of allergen positive skin-prick tests in a sample of Italian and Polish schoolchildren. A total of 336 unselected 9-year-old-schoolchildren (198 in Italy and 138 in Poland) underwent skin-prick tests with three different histamine concentrations (10, 1 and 0.2 mg/ml) and with a panel of common airborne allergens according to the ISAAC protocol, phase two. Mean wheals elicited by skin-prick tests with the three serial concentrations of histamine were significantly larger (p < 0.001) and shifted more toward higher values (p < 0.001) in Italian than in Polish children. The differences were greater for the intermediate histamine concentration tested (1 mg/ml) than for the highest concentration (10 mg/ml). Skin-prick tests for airborne allergens were more frequently positive in Italian children: wheals >or= 3 mm induced by any allergen [odds ratio (OR) 1.69; confidence interval (CI) 0.98-2.92] by Dermatophagoides pteronyssinus (OR 1.92; CI 0.97-3.80) and by D. farinae (OR 3.15; CI 1.16-8.63). Labeling as positive allergen wheal reactions half the size of the 10 mg/ml histamine wheal or larger reduced but did not abolish the Italian-Polish differences. The significantly higher skin histamine reactivity observed in Italian children could help to explain why allergen skin-test reactions differ in the East and West European populations. Moreover, differences in nonallergen-specific factors among populations should be considered in the interpretation of skin test results (e.g. cut-off points). To obtain meaningful results, epidemiological studies of allergies should include serial histamine dilutions.

Nasal cellularity in 183 unselected schoolchildren aged 9 to 11 years.

OBJECTIVE: Although rhinitis is extremely frequent in children, methods for assessing the severity of nasal inflammation produce results with wide variability and hence weak clinical significance. We designed this epidemiologic investigation to define the clinical usefulness of assessing nasal cellularity in children. METHODS: We studied 183 of 203 eligible unselected schoolchildren who were aged 9 to 11 years and whose parents gave informed consent and completed a questionnaire on the history of atopic and respiratory symptoms. In all children, nasal swabs were obtained from both nostrils and eluted in saline and slides were prepared from cytospin preparations for staining and white cell counts. Children also underwent determination of nasal volume, skin prick tests with 7 common local allergens, flow volume curves, and nitric oxide measurement in expired air. Blood samples were drawn for the measurement of total immunoglobulin E, eosinophil percentage, and detection of Chlamydia pneumoniae antibodies. C pneumoniae DNA was also sought in eluates from nasal swabs. The percentage, standard deviations, and percentiles of the various nasal white cell populations were determined. RESULTS: No correlation of the percentage of these cells was found with the history of allergies or respiratory disease or with functional or laboratory finding. Repeat nasal swabs obtained 1 month after the initial examination in 31 children (20 with neutrophils higher and 11 lower than 14%) in 77.4% of the cases confirmed the previous (high or normal) result. Twelve of the 16 eligible children with persistently high nasal neutrophil counts completed a 15-day cycle of intranasal flunisolide therapy (200 micro g twice a day). Therapy significantly reduced nasal neutrophil percentage and increased nasal volume. CONCLUSIONS: Increased nasal neutrophils, although related neither to the clinical history nor to laboratory variables, are a common important finding in children. A 15-day cycle of intranasal flunisolide is sufficient to restore normal nasal neutrophilia.