Pletismografía corporal (I): estandarización y criterios de calidad / Body plethysmography (I): Standardisation and quality criteria

La pletismografía corporal completa permite la medición de volúmenes, capacidades y resistencias pulmonares. Es una técnica bien estandarizada y ampliamente utilizada en neumología pediátrica, aunque requiere equipo específico, personal especializado y cierta colaboración por parte del paciente. La pletismografía utiliza la ley de Boyle para determinar el volumen de gas intratorácico o capacidad residual funcional, y una vez determinada esta, se extrapolan el volumen residual y la capacidad pulmonar total. La medición de la capacidad pulmonar total es necesaria para el diagnóstico de patología restrictiva. La resistencia de la vía aérea es una medida de obstrucción, pudiéndose determinar la resistencia total, que incluye la resistencia de la pared torácica, tejido pulmonar y vía aérea, y la resistencia específica, que es un parámetro más estable que corresponde al producto de la resistencia de la vía aérea por la capacidad residual funcional. La complejidad de esta técnica, las ecuaciones de referencia, las diferencias en el equipamiento, la variabilidad de la misma y las condiciones en las que se realiza han hecho necesaria su estandarización. Se analizan a lo largo del artículo los aspectos prácticos de esta técnica, especificando las recomendaciones para su realización, sistemática de calibración y los cálculos que se deben llevar a cabo, así como la interpretación de los resultados obtenidos. El objetivo de esta publicación es favorecer una mejor comprensión de los principios de la pletismografía completa con el fin de optimizar la interpretación de los resultados favoreciendo un mejor manejo del paciente y un consenso en la especialidad (AU)

Whole body plethysmography is used to measure lung volumes, capacities and resistances. It is a well standardised technique, and although it is widely used in paediatric chest diseases units, it requires specific equipment, specialist staff, and some cooperation by the patient. Plethysmography uses Boyle's law in order to measure the intrathoracic gas volume or functional residual capacity, and once this is determined, the residual volume and total lung capacity is extrapolated. The measurement of total lung capacity is necessary for the diagnosis of restrictive diseases. Airway resistance is a measurement of obstruction, with the total resistance being able to be measured, which includes chest wall, lung tissue and airway resistance, as well as the specific airway resistance, which is a more stable parameter that is determined by multiplying the measured values of airway resistance and functional residual capacity. The complexity of this technique, the reference equations, the differences in the equipment and their variability, and the conditions in which it is performed, has led to the need for its standardisation. Throughout this article, the practical aspects of plethysmography are analysed, specifying recommendations for performing it, its systematic calibration and the calculations that must be made, as well as the interpretation of the results obtained. The aim of this article is to provide a better understanding of the principles of whole body plethysmography with the aim of optimising the interpretation of the results, leading to improved management of the patient, as well as a consensus among the speciality (AU)

Medición de la difusión de CO (II): estandarización y criterios de calidad / Measurement of CO diffusion capacity (II): Standardization and quality criteria

La capacidad de difusión es la técnica que mide la capacidad del aparato respiratorio para realizar el intercambio gaseoso y así diagnosticar la disfunción de la unidad alvéolo-capilar. El parámetro más importante a evaluar es la capacidad de difusión del CO (DLCO). Actualmente hay nuevos métodos para medir la capacidad de difusión utilizando óxido nítrico (NO). Existen diferentes métodos de medida, aunque en este artículo nos referiremos sobre todo a la técnica de la respiración única, la más utilizada y mejor estandarizada. Su complejidad, sus ecuaciones de referencia, las diferencias en equipamiento, la variabilidad interpacientes y las condiciones en las que se realiza hacen que exista una gran variabilidad interlaboratorio, habiéndose realizado estandarizaciones para hacer este método más fiable y reproducible. Se analizan los aspectos prácticos de la técnica, especificando las recomendaciones para la realización de un procedimiento adecuado, sistemática de calibración y cálculos y ajustes necesarios. También se exponen sus aplicaciones clínicas. Se produce un aumento de la transferencia de CO en las enfermedades en las que existe un aumento del volumen sanguíneo en los capilares pulmonares, en la policitemia y en la hemorragia pulmonar. Existe una disminución de la DLCO en los pacientes con reducción del volumen alveolar o en los defectos de difusión, ya sea por alteración de la membrana alvéolo-capilar (enfermedad intersticial) o por disminución del volumen de sangre en los capilares pulmonares (embolia pulmonar o hipertensión pulmonar primaria). También se exponen otras causas de disminución o aumento de la DLCO

The diffusion capacity is the technique that measures the ability of the respiratory system for gas exchange, thus allowing a diagnosis of the malfunction of the alveolar-capillary unit. The most important parameter to assess is the CO diffusion capacity (DLCO). New methods are currently being used to measure the diffusion using nitric oxide (NO). There are other methods for measuring diffusion, although in this article the single breath technique is mainly referred to, as it is the most widely used and best standardized. Its complexity, its reference equations, differences in equipment, inter-patient variability and conditions in which the DLCO is performed, lead to a wide inter-laboratory variability, although its standardization makes this a more reliable and reproductive method. The practical aspects of the technique are analyzed, by specifying the recommendations to carry out a suitable procedure, the calibration routine, calculations and adjustments. Clinical applications are also discussed. An increase in the transfer of CO occurs in diseases in which there is an increased volume of blood in the pulmonary capillaries, such as in the polycythemia and pulmonary hemorrhage. There is a decrease in DLCO in patients with alveolar volume reduction or diffusion defects, either by altered alveolar-capillary membrane (interstitial diseases) or decreased volume of blood in the pulmonary capillaries (pulmonary embolism or primary pulmonary hypertension). Other causes of decreased or increased DLCO are also highlighted

[Body plethysmography (I): Standardisation and quality criteria]. / Pletismografía corporal (I): estandarización y criterios de calidad.

Whole body plethysmography is used to measure lung volumes, capacities and resistances. It is a well standardised technique, and although it is widely used in paediatric chest diseases units, it requires specific equipment, specialist staff, and some cooperation by the patient. Plethysmography uses Boyle's law in order to measure the intrathoracic gas volume or functional residual capacity, and once this is determined, the residual volume and total lung capacity is extrapolated. The measurement of total lung capacity is necessary for the diagnosis of restrictive diseases. Airway resistance is a measurement of obstruction, with the total resistance being able to be measured, which includes chest wall, lung tissue and airway resistance, as well as the specific airway resistance, which is a more stable parameter that is determined by multiplying the measured values of airway resistance and functional residual capacity. The complexity of this technique, the reference equations, the differences in the equipment and their variability, and the conditions in which it is performed, has led to the need for its standardisation. Throughout this article, the practical aspects of plethysmography are analysed, specifying recommendations for performing it, its systematic calibration and the calculations that must be made, as well as the interpretation of the results obtained. The aim of this article is to provide a better understanding of the principles of whole body plethysmography with the aim of optimising the interpretation of the results, leading to improved management of the patient, as well as a consensus among the speciality.

[Measurement of CO diffusion capacity (II): Standardization and quality criteria]. / Medición de la difusión de CO (II): estandarización y criterios de calidad.

The diffusion capacity is the technique that measures the ability of the respiratory system for gas exchange, thus allowing a diagnosis of the malfunction of the alveolar-capillary unit. The most important parameter to assess is the CO diffusion capacity (DLCO). New methods are currently being used to measure the diffusion using nitric oxide (NO). There are other methods for measuring diffusion, although in this article the single breath technique is mainly referred to, as it is the most widely used and best standardized. Its complexity, its reference equations, differences in equipment, inter-patient variability and conditions in which the DLCO is performed, lead to a wide inter-laboratory variability, although its standardization makes this a more reliable and reproductive method. The practical aspects of the technique are analyzed, by specifying the recommendations to carry out a suitable procedure, the calibration routine, calculations and adjustments. Clinical applications are also discussed. An increase in the transfer of CO occurs in diseases in which there is an increased volume of blood in the pulmonary capillaries, such as in the polycythemia and pulmonary hemorrhage. There is a decrease in DLCO in patients with alveolar volume reduction or diffusion defects, either by altered alveolar-capillary membrane (interstitial diseases) or decreased volume of blood in the pulmonary capillaries (pulmonary embolism or primary pulmonary hypertension). Other causes of decreased or increased DLCO are also highlighted.

Tratamientos respiratorios en la enfermedad neuromuscular / Respiratory treatments in neuromuscular disease

Revisadas en un artículo anterior la fisiopatología respiratoria del enfermo neuromuscular (ENM), así como su evaluación clínica y las principales complicaciones causantes de su deterioro pulmonar, en el presente artículo se describen los tratamientos respiratorios necesarios para preservar la función pulmonar del ENM durante el mayor tiempo posible, así como en situaciones especiales (infecciones respiratorias, cirugía de escoliosis, etc.). Se hace especial hincapié en la utilidad de la ventilación no invasiva cuyo uso está cambiando la historia natural de muchas de estas enfermedades. La prolongación de la vida en estos niños permite que lleguen a las unidades de neumología de adultos para proseguir su atención. La transición desde la pediatría debe ser un proceso activo, progresivo en el tiempo y poco estresante para el paciente ante la adaptación a ese nuevo entorno, manteniendo siempre una atención multidisciplinar

In a previous article, a review was presented of the respiratory pathophysiology of the patient with neuromuscular disease, as well as their clinical evaluation and the major complications causing pulmonary deterioration. This article presents the respiratory treatments required to preserve lung function in neuromuscular disease as long as possible, as well as in special situations (respiratory infections, spinal curvature surgery, etc.). Special emphasis is made on the use of non-invasive ventilation, which is changing the natural history of many of these diseases. The increase in survival and life expectancy of these children means that they can continue their clinical care in adult units. The transition from pediatric care must be an active, timely and progressive process. It may be slightly stressful for the patient before the adaptation to this new environment, with multidisciplinary care always being maintained

[Respiratory treatments in neuromuscular disease]. / Tratamientos respiratorios en la enfermedad neuromuscular.

In a previous article, a review was presented of the respiratory pathophysiology of the patient with neuromuscular disease, as well as their clinical evaluation and the major complications causing pulmonary deterioration. This article presents the respiratory treatments required to preserve lung function in neuromuscular disease as long as possible, as well as in special situations (respiratory infections, spinal curvature surgery, etc.). Special emphasis is made on the use of non-invasive ventilation, which is changing the natural history of many of these diseases. The increase in survival and life expectancy of these children means that they can continue their clinical care in adult units. The transition from pediatric care must be an active, timely and progressive process. It may be slightly stressful for the patient before the adaptation to this new environment, with multidisciplinary care always being maintained.

Impacto de una intervención educativa sobre asma en los profesores / Impact of an asthma educational intervention programme on teachers

Objetivo: Determinar el impacto de una intervención educativa en el nivel de conocimientos de los profesores sobre el asma y su manejo. Material y método: Estudio cuasiexperimental, de tipo antes y después, con grupo control, de una intervención educativa (IE) dirigida a mejorar el grado de conocimientos sobre el asma infantil y su manejo en profesores de centros escolares de San Sebastián (Gipuzkoa). Se utilizó como elemento de medida el cuestionario de conocimientos Newcastle Asthma Knowledge Questionnaire (NAKQ) y como intervención educativa, una adaptación del programa Asma, Deporte y Salud. Se utilizó el test de los rangos con signo de Wilcoxon para comparar la puntuación total en el cuestionario antes y después de la intervención, el test de McNemar para comparar el porcentaje de respuestas correctas a cada ítem y el test U de Mann-Whitney para la comparación en la puntuación basal y a los 3 meses entre el grupo de intervención y el grupo control. Se estudiaron el tamaño del efecto y la respuesta media estandarizada. Resultados: Participaron 138 docentes de 6 centros elegidos aleatoriamente (grupo estudio) y 43 en el grupo control. En el grupo estudiado la puntuación media del cuestionario de conocimientos de asma NAKQ antes de la realización de la intervención educativa fue de 16,1±3,4 puntos, con una mediana de 16 (rango 7-23). Tras la intervención educativa, la puntuación ascendió a 22,3±4,1 con una mediana de 23 (rango 6-29), siendo la diferencia media en la puntuación global de conocimientos de 7,0±4,2 puntos, con una mediana de 8 (rango -2; 17), tamaño del efecto de 2,0(>0,8) siendo la respuesta media estandarizada de 1,7. A los 3 meses de la intervención, la puntuación media del cuestionario fue de 21,4±3,0 puntos, con una mediana de 22 (rango 12-29), significativamente superior al momento previo a la intervención (p<0,001) y algo menor que el inmediatamente posterior a la misma, suponiendo un tamaño del efecto de 1,6 y una respuesta media estandarizada de 1,2. En el grupo control no se modificó el nivel de conocimientos, permaneciendo más bajo que el grupo intervenido (p<0,001). Conclusiones: Una intervención educativa dirigida a los profesores aumenta significativamente el nivel de conocimientos sobre el asma. Además, el incremento disminuye algo pero se mantiene elevado durante al menos 3 meses. Algunos aspectos del conocimiento, aunque mejoran con la intervención educativa, no son óptimos (AU)

Objective: Our objective was to measure the impact of an educational intervention program on teacher's knowledge about asthma and its management. Material and method: Before and after quasi-experimental study, with control group, of an educational intervention, which had as its aim to improve the teacher's knowledge of asthma and its management, was conducted in some schools of San Sebastian (Gipuzkoa), Spain. The Newcastle Asthma knowledge Questionnaire (NAKQ) was used as a measuring tool, and an adaptation of the asthma, sport and health program was used as an educational intervention. The Wilcoxon signed rank test was used to compare the total score of the questionnaire before and after the intervention, and the McNemar test was performed to compare the percentages of correct answers to each item. The Mann-Whitney U test was also performed to compare the baseline score and the score at three months between the intervention group and control group. The size of the effect and the standardised mean response were studied. Results: A total of 138 teachers from 6 schools, which were chosen at random (study group), and 43 teachers in the control group participated in the study. In the study group, the mean score of the NAKQ before the educational intervention was 16.1±3.4 points, with a median of 16 (range 7 to 23). After the intervention the mean score increased to 22.3±4.1, with a median of 23 (range, 6 to 29). The mean difference in the overall score of the NAKQ was 7.0±4.2 points, with a median of 8 (range, -2 to17). Furthermore, the size of the effect was 2.0 (> 0.8) and the standardised mean response was 1.7. After 3 months of the intervention the mean score of the NAKQ was 21.4±3.0 points, with a median of 22 (range, 12 to 29) which was significantly higher than the score obtained before the intervention (P<0.001) and slightly lower than the score obtained immediately after the intervention, assuming a size of the effect of 1.6 and a standardised mean response of 1.2. In the control group, the level of knowledge did not change modified and was lower than the level of the intervention group (P<0.001). Conclusions: An educational intervention program conducted among teachers significantly increases their knowledge of asthma. Moreover, the increase reduces slightly but maintains its higher level for at least 3 months. In spite of the fact that some aspects of knowledge improved with the educational intervention, they were not optimal (AU)

[Impact of an asthma educational intervention programme on teachers]. / Impacto de una intervención educativa sobre asma en los profesores.

OBJECTIVE: Our objective was to measure the impact of an educational intervention program on teacher's knowledge about asthma and its management. MATERIAL AND METHOD: Before and after quasi-experimental study, with control group, of an educational intervention, which had as its aim to improve the teacher's knowledge of asthma and its management, was conducted in some schools of San Sebastian (Gipuzkoa), Spain. The Newcastle Asthma knowledge Questionnaire (NAKQ) was used as a measuring tool, and an adaptation of the asthma, sport and health program was used as an educational intervention. The Wilcoxon signed rank test was used to compare the total score of the questionnaire before and after the intervention, and the McNemar test was performed to compare the percentages of correct answers to each item. The Mann-Whitney U test was also performed to compare the baseline score and the score at three months between the intervention group and control group. The size of the effect and the standardised mean response were studied. RESULTS: A total of 138 teachers from 6 schools, which were chosen at random (study group), and 43 teachers in the control group participated in the study. In the study group, the mean score of the NAKQ before the educational intervention was 16.1±3.4 points, with a median of 16 (range 7 to 23). After the intervention the mean score increased to 22.3±4.1, with a median of 23 (range, 6 to 29). The mean difference in the overall score of the NAKQ was 7.0±4.2 points, with a median of 8 (range, -2 to17). Furthermore, the size of the effect was 2.0 (> 0.8) and the standardised mean response was 1.7. After 3 months of the intervention the mean score of the NAKQ was 21.4±3.0 points, with a median of 22 (range, 12 to 29) which was significantly higher than the score obtained before the intervention (P<.001) and slightly lower than the score obtained immediately after the intervention, assuming a size of the effect of 1.6 and a standardised mean response of 1.2. In the control group, the level of knowledge did not change modified and was lower than the level of the intervention group (P<.001). CONCLUSIONS: An educational intervention program conducted among teachers significantly increases their knowledge of asthma. Moreover, the increase reduces slightly but maintains its higher level for at least 3 months. In spite of the fact that some aspects of knowledge improved with the educational intervention, they were not optimal.

Association among lung function, exhaled nitric oxide, and the CAN questionnaire to assess asthma control in children.

BACKGROUND: The aim of this study was to investigate the association among a validated symptom-based questionnaire for asthma control in children (CAN), forced expiratory volume in 1 sec (FEV(1)), and fractional exhaled nitric oxide (FE(NO)). METHODS: Observational cross-sectional study was performed in a consecutive sample of asthmatic children aged between 7 and 14 years old from December 2007 to February 2008. FE(NO) was measured with a portable electrochemical analyzer and forced spirometry was performed according to American Thoracic Society/European Respiratory Society. The CAN questionnaire was completed by the parents (aged <9 years old) or by the children (> or = 9 years old). The strength of the association among FEV(1), FE(NO), and CAN questionnaire was studied using Spearman's rho, and the degree of agreement for asthma control among FEV(1), FE(NO), and CAN questionnaire, with classification of these variables according to values of normality, was studied using Pearson's chi(2) test and Cohen's kappa (KC). RESULTS: We studied 268 children, mean age 9.7 +/- 2.1 years. Significant correlations were found between FE(NO) and CAN (r = 0.2), between FEV(1) and CAN (r = -0.3), and between FE(NO) and FEV(1) (r = -0.12). On classifying the variables according to values of normality, no agreement was found to establish the degree of asthma control between FE(NO) and CAN (KC = 0.18, chi(2) Pearson = 9.63); between FEV(1) and CAN (KC = 0.29, chi(2) = 38.5); or between FE(NO) and FEV(1) (KC = 0.07, chi(2) = 4.9). CONCLUSIONS: The association among the three measurement instruments used to assess asthma control (FEV(1), FE(NO), and CAN) was weak. These are instruments that quantify variables that influence asthma in different ways, in this sense, none can be used instead of another in asthma management although they are complementary.

[Recurrent wheezing in three year-olds: facts and opportunities]. / Sibilancias recurrentes en menores de tres años: evidencias y oportunidades.

The 3 year-old group of children has an increased incidence and prevalence of recurrent wheezing episodes. There are different subgroups, who give different inflammatory responses to different triggering agents, and subgroups that differ in aetiopathology and immunopathology. Current diagnostic methods (exhaled nitric oxide in multiple breaths, nitric oxide in exhaled air condensate, induced sputum, broncho-alveolar lavage and endo-bronchial biopsy), enable the inflammatory pattern to be identified and to give the most effective and safe treatment. The various therapeutic options for treatment are reviewed, such as inhaled glucocorticoids when the inflammatory phenotype is eosinophilic, and leukotriene receptor antagonists, when the inflammatory phenotype is predominantly neutrophilic. In accordance with the current recommendations, for the diagnosis as well as for the therapy initiated in children of this age, they must be regularly reviewed, so that if the benefit is not clear, the treatment must be stopped and an alternative diagnosis and treatment considered. The start of treatment should be determined depending on the intensity and frequency of the symptoms, with the aim of decreasing morbidity and increasing the quality of life of the patient.

Sibilancias recurrentes en menores de tres años: evidencias y oportunidades / Recurrent wheezing in three year-olds: facts and opportunities

El grupo de niños menores de 3 años presenta una elevada incidencia y prevalencia de episodios de sibilancias recurrentes, con distintos subgrupos que expresan diferentes respuestas inflamatorias ante agentes desencadenantes diversos, subgrupos que difieren en etiopatogenia e inmunopatología. Los métodos diagnósticos de los que se dispone en la actualidad (óxido nítrico exhalado a respiraciones múltiples, óxido nítrico en el condensado de aire exhalado, esputo inducido, lavado broncoalveolar y biopsia endobronquial) permiten identificar el patrón inflamatorio y realizar un tratamiento que resulte más eficaz y más seguro. Se revisan las distintas opciones terapéuticas, entre las que se incluyen los glucocorticoides inhalados cuando el fenotipo inflamatorio es eosinofílico y los antagonistas de los receptores de los leucotrienos cuando el fenotipo inflamatorio es de predominio neutrofílico. De acuerdo con las recomendaciones actuales, tanto el diagnóstico como la terapia iniciada en los niños de esta edad deben revisarse regularmente, de tal modo que si el beneficio no está claro, el tratamiento debe suspenderse y considerar un diagnóstico o tratamiento alternativo. El inicio del tratamiento deberá ser determinado en función de la intensidad y de la frecuencia de los síntomas, con el objetivo de disminuir la morbilidad y aumentar la calidad de vida del paciente (AU)

The 3 year-old group of children has an increased incidence and prevalence of recurrent wheezing episodes. There are different subgroups, who give different inflammatory responses to different triggering agents, and subgroups that differ in aetiopathology and immunopathology. Current diagnostic methods (exhaled nitric oxide in multiple breaths, nitric oxide in exhaled air condensate, induced sputum, broncho-alveolar lavage and endo-bronchial biopsy), enable the inflammatory pattern to be identified and to give the most effective and safe treatment. The various therapeutic options for treatment are reviewed, such as inhaled glucocorticoids when the inflammatory phenotype is eosinophilic, and leukotriene receptor antagonists, when the inflammatory phenotype is predominantly neutrophilic. In accordance with the current recommendations, for the diagnosis as well as for the therapy initiated in children of this age, they must be regularly reviewed, so that if the benefit is not clear, the treatment must be stopped and an alternative diagnosis and treatment considered. The start of treatment should be determined depending on the intensity and frequency of the symptoms, with the aim of decreasing morbidity and increasing the quality of life of the patient (AU)

[Fractional exhaled nitric oxide: validation of a 6 second exhalation time with two different analysers]. / Fracción exhalada de óxido nítrico: validación de la medida con tiempo de espiración de 6 s con dos analizadores diferentes.

OBJECTIVE: To validate the measurement of fractional exhaled nitric oxide concentration (FE(NO)) using a 6-sec exhalation time in patients aged between 5 and 17 years with a stationary chemiluminescence analyser (NIOX, Aerocrine) and a portable electrochemical analyser (NIOX-MINO, Aerocrine). MATERIAL AND METHODS: FE(NO) was assessed in 60 patients randomised into two groups. In Group 1 (n = 30, NIOX analyser), three valid FE(NO) measurements were obtained for two exhalation times (10 sec and 6 sec); the mean of the three measurements was recorded. In Group 2 (n = 30, NIOX-MINO), a single valid measurement of FE(NO) was obtained for each exhalation time. We analysed age, gender, weight, height, diagnosis, treatment, FE(NO) and the number of attempts with both exhalation times in each analyser. Agreement between FE(NO) assessed using 10-sec and 6-sec exhalations was assessed by Bland-Altman analysis and Cohen's kappa. RESULTS: The mean (SD) age in Group 1 was 10.1 (3.07) years. The mean age in Group 2 was 10.43 (2.94) years. Bland-Altman analysis demonstrated good agreement between FE(NO) values obtained with both exhalation times and with both devices. Cohen's kappa, also demonstrated good agreement (NIOX, kappa = 1; NIOX-MINO, kappa = 0.93). CONCLUSIONS: A 6-sec exhalation time is valid for measuring FE(NO) with both analysers in children aged over 5 years.

Fracción exhalada de óxido nítrico: validación de la medida con tiempo de espiración de 6 s con dos analizadores diferentes / Fractional exhaled nitric oxide: Validation of a 6 second exhalation time with two different analysers

Objetivo. Validar la determinación de la fracción exhalada de óxido nítrico (FENO) con tiempo de espiración de 6 s con un analizador de quimioluminiscencia estacionario (NIOX(R), Aerocrine) y con un analizador electroquímico portátil (NIOX-MINO(R), Aerocrine). Material y métodos. Determinaciones de la FENO en 60 pacientes entre 5 y 17 años. Grupo 1 (n=30, NIOX(R)): tres medidas válidas para cada tiempo de espiración (10 y 6 s) y cálculo de la media de las tres determinaciones. Grupo 2 (n=30, NIOX-MINO(R)): una determinación válida con cada tiempo de espiración. Variables: edad, sexo, peso, talla, diagnóstico, tratamiento, FENO y número de intentos con cada tiempo de espiración en cada analizador. Análisis de concordancia y grado de acuerdo entre los valores de FENO obtenidos con cada dispositivo, con tiempos espiratorios de 10 y 6 s mediante el método Bland y Altman y la kappa de Cohen (κ). Resultados. Grupo 1 (NIOX(R)), edad media 10,1 ± 3,07 años. Grupo 2 (NIOX-MINO(R)), edad media 10,43 ± 2,94 años. Existe una buena concordancia entre los valores obtenidos con NIOX(R) y con NIOX-MINO(R) a 10 y 6 s. Hubo un acuerdo sustancial entre los valores obtenidos con NIOX(R) a 10 y 6 s ( κ=1) y con NIOX-MINO(R) a 10 y 6 s ( κ=0,93). Conclusiones. El tiempo de espiración de 6 s es válido para la determinación de la FENO con cada uno de los dispositivos de medida en niños mayores de 5 años

Objective. To validate the measurement of fractional exhaled nitric oxide concentration (FENO) using a 6-sec exhalation time in patients aged between 5 and 17 years with a stationary chemiluminescence analyser (NIOX(R), Aerocrine) and a portable electrochemical analyser (NIOX-MINO(R), Aerocrine). Material and methods. FENO was assessed in 60 patients randomised into two groups. In Group 1 (n = 30, NIOX(R) analyser), three valid FENO measurements were obtained for two exhalation times (10 sec and 6 sec); the mean of the three measurements was recorded. In Group 2 (n = 30, NIOX-MINO(R)), a single valid measurement of FENO was obtained for each exhalation time. We analysed age, gender, weight, height, diagnosis, treatment, FENO and the number of attempts with both exhalation times in each analyser. Agreement between FENO assessed using 10-sec and 6-sec exhalations was assessed by Bland-Altman analysis and Cohen's kappa. Results. The mean (SD) age in Group 1 was 10.1 (3.07) years. The mean age in Group 2 was 10.43 (2.94) years. Bland-Altman analysis demonstrated good agreement between FENO values obtained with both exhalation times and with both devices. Cohen's kappa, also demonstrated good agreement (NIOX(R), κ = 1; NIOX-MINO(R), κ = 0.93). Conclusions. A 6-sec exhalation time is valid for measuring FENO with both analysers in children aged over 5 years

[Spanish version of the TNO-AZL preschool children quality of life questionnaire (TAPQOL)]. / Versión española del TAPQOL: calidad de vida relacionada con la salud en niños de 3 meses a 5 años.

OBJECTIVES: To obtain a Spanish version of the TNO-AZL Preschool Children Quality of Life Questionnaire (TAPQOL) that would be both semantically and culturally equivalent to the original. MATERIAL AND METHODS: The TAPQOL questionnaire was designed to measure health-related quality of life in children aged 3 months to 5 years and contains 43 questions distributed in 12 subdimensions. The Spanish version was obtained by using the forward/back-translation method with expert, bilingual translators. Cognitive debriefing interviews were carried out with the parents of healthy children and with those of children with respiratory disease. RESULTS: During the adaptation phase, four items were modified after input from the authors of the original version to retain the meaning of the original. At the end of the adaptation process, 37 of the 43 items were classified as A, i.e. without difficulty in the adaptation. Four mothers and two fathers participated in the cognitive debriefing interviews. Four had secondary level education, and two had university level education. Their children were aged between 16 and 60 months. The average time taken to complete the questionnaire was 13.5 minutes. No comprehension problems regarding the questionnaire's content were found, and no items were modified after this phase of the study. The mothers of children with respiratory disease considered the questions related to their children's symptoms to be appropriate. CONCLUSIONS: The Spanish version of the TAPQOL has proven to be acceptable and culturally equivalent to the original version. Future studies should investigate the psychometric properties of this questionnaire and compare them with those of the original version.

Versión española del TAPQOL: calidad de vida relacionada con la salud en niños de 3 meses a 5 años / Spanish version of the TNO-AZL preschool children quality of life questionnaire (TAPQOL)

Objetivos: Obtener una versión española del cuestionario TNO-AZL Preschool Children Quality of Life (TAPQOL) semántica y culturalmente equivalente a la versión original. Material y métodos: El cuestionario TAPQOL ha sido diseñado para medir la calidad de vida relacionada con la salud en niños de 3 meses a 5 años y contiene 43 preguntas incluidas en 12 subdimensiones. Para obtener la versión en español se ha seguido la metodología de traducción directa e inversa con traductores expertos bilingües. Se llevaron a cabo entrevistas cognitivas con madres y padres de niños sanos y con patología respiratoria. Resultados: Durante la fase de adaptación se modificaron cuatro ítems a partir de los comentarios de los autores originales para retener el sentido de los conceptos de la versión original. Al final del proceso, 37 de los 43 ítems del cuestionario fueron clasificados como A, sin dificultad en la adaptación. En las entrevistas cognitivas, contestaron cuatro madres y dos padres, cuatro de ellos con nivel de estudios secundarios y dos de nivel universitario, de niños de entre 16 y 60 meses. El promedio para contestar el cuestionario fue de 13,5 min. No hubo problemas en la comprensión de los contenidos del cuestionario y no se modificó ningún ítem después de esta fase del estudio. Las madres de niños con patología respiratoria consideraron adecuadas las preguntas relacionadas con los síntomas de sus hijos. Conclusiones: La versión española del cuestionario TAPQOL es aceptable y equivalente culturalmente a la versión original. Futuros estudios deberán comprobar sus propiedades psicométricas y compararlas con la versión original (AU)

Objectives: To obtain a Spanish version of the TNO-AZL Preschool Children Quality of Life Questionnaire (TAPQOL) that would be both semantically and culturally equivalent to the original. Material and methods: The TAPQOL questionnaire was designed to measure health-related quality of life in children aged 3 months to 5 years and contains 43 questions distributed in 12 subdimensions. The Spanish version was obtained by using the forward/back-translation method with expert, bilingual translators. Cognitive debriefing interviews were carried out with the parents of healthy children and with those of children with respiratory disease. Results: During the adaptation phase, four items were modified after input from the authors of the original version to retain the meaning of the original. At the end of the adaptation process, 37 of the 43 items were classified as A, i.e. without difficulty in the adaptation. Four mothers and two fathers participated in the cognitive debriefing interviews. Four had secondary level education, and two had university level education. Their children were aged between 16 and 60 months. The average time taken to complete the questionnaire was 13.5 minutes. No comprehension problems regarding the questionnaire’s content were found, and no items were modified after this phase of the study. The mothers of children with respiratory disease considered the questions related to their children’s symptoms to be appropriate. Conclusions: The Spanish version of the TAPQOL has proven to be acceptable and culturally equivalent to the original version. Future studies should investigate the psychometric properties of this questionnaire and compare them with those of the original version (AU)

[Agreement between two devices for measuring exhaled nitric oxide]. / Concordancia entre dos dispositivos de medida de óxido nítrico exhalado.

BACKGROUND: Measurement of fractional exhaled nitric oxide (FENO) is a non-invasive marker of eosinophilic airway inflammation that can be useful in asthma diagnosis and control, as well as in treatment monitoring. OBJECTIVE: We studied the correlation between two techniques for measuring FENO: the chemiluminescence-based analyzer (NIOX, Aerocrine, Sweden) and a new portable electrochemical sensor-based analyzer (NIOX-MINO, Aerocrine). MATERIAL AND METHODS: FENO was measured by the single breath on-line method. In all children, three consecutives measurements were obtained with NIOX, with a maximum of six attempts, and the arithmetic mean was calculated. Next, using NIOX-MINO, a single measurement was made successively in each of the children. The variables analyzed were sex, age, height, weight, diagnosis, treatment, NIOX-MINO value, mean of three values obtained with NIOX and the NO elimination rate (nL/min). For the statistical analysis, the Bland-Altman plot was used to compare the means and the differences between measurements of FENO from NIOX and NIOX-MINO. The agreement between the two analyzers was estimated by Cohen's Kappa statistic. RESULTS: Thirty children were included, 14 (46.67%) boys and 16 (53.33%) girls. The mean age was 11.3+/-3.09 years. All of the children successfully performed the measurements with two analyzers. The relationship between the means and the differences in the values obtained with NIOX-MINO and NIOX were statistically significant (p<0.005). In addition, Cohen's Kappa statistic (0.78) suggested a high degree of agreement between the results obtained with the two devices. CONCLUSIONS: The two analyzers, NIOX-MINO and NIOX, were not equivalent. There was good agreement between the FENO values measured with the two devices. Measurement of FENO with the portable electrochemical sensor-based analyzer (NIOX-MINO) is valid and feasible in children older than 5 years.

Concordancia entre dos dispositivos de medida de óxido nítrico exhalado / Agreement between two devices for measuring exhaled nitric oxide

Antecedentes La fracción exhalada de óxido nítrico (FENO) se comporta como un marcador no invasivo de inflamación eosinófila de la vía aérea, que resulta de utilidad en el diagnóstico de asma, en el control de la enfermedad y en la monitorización del tratamiento. Objetivo Analizar la concordancia entre dos dispositivos de medida de la FENO, un analizador de quimioluminiscencia estacionario (NIOX(R), Aerocrine, Suecia) y un analizador electroquímico portátil (NIOX-MINO(R), Aerocrine, Suecia). Material y métodos Las medidas se han realizado mediante registro on-line de respiración única (single breath on-line measurement). Se han obtenido tres medidas consecutivas con el analizador NIOX(R), máximo de seis intentos, y se ha calculado la media. Asimismo, y de forma sucesiva en cada uno de los niños, se realizó otra medición con el analizador NIOX-MINO(R). Se han analizado las variables cuantitativas edad, talla, peso, valor NIOX-MINO(R), valor medio NIOX(R) y flujo de óxido nítrico (NO) (nl/min), y las variables cualitativas sexo, diagnóstico y tratamiento. En el análisis estadístico se han estudiado la regresión de las medias de FENO (Bland-Altman) y el grado de acuerdo entre ambos dispositivos (estadístico kappa de Cohen). Resultados Se han estudiado 30 niños, edad media 11,3 ± 3,09 años, distribuidos en 14 varones (46,67 %) y 16 mujeres (53,33 %). El 100 % de los casos realizaron con éxito las mediciones con ambos dispositivos. La regresión de las medias obtenidas fue significativa, tanto en valores absolutos como relativos. Asimismo, hubo acuerdo entre los resultados con ambos dispositivos (kappa de Cohen, 0,78). Conclusiones Los dos sistemas estudiados de determinación de la FENO no son equivalentes. Existe entre ambas técnicas un acuerdo sustancial en las determinaciones obtenidas. La FENO determinada mediante técnica electroquímica con sistemas portátiles es válida en niños mayores de 5 años

Background Measurement of fractional exhaled nitric oxide (FENO) is a non-invasive marker of eosinophilic airway inflammation that can be useful in asthma diagnosis and control, as well as in treatment monitoring. Objective We studied the correlation between two techniques for measuring FENO: the chemiluminescence-based analyzer (NIOX(R), Aerocrine, Sweden) and a new portable electrochemical sensor-based analyzer (NIOX-MINO(R), Aerocrine). Material and methods FENO was measured by the single breath on-line method. In all children, three consecutives measurements were obtained with NIOX(R), with a maximum of six attempts, and the arithmetic mean was calculated. Next, using NIOX-MINO(R), a single measurement was made successively in each of the children. The variables analyzed were sex, age, height, weight, diagnosis, treatment, NIOX-MINO(R) value, mean of three values obtained with NIOX(R) and the NO elimination rate (nL/min). For the statistical analysis, the Bland-Altman plot was used to compare the means and the differences between measurements of FENO from NIOX(R) and NIOX-MINO(R). The agreement between the two analyzers was estimated by Cohen's Kappa statistic. Results Thirty children were included, 14 (46.67 %) boys and 16 (53.33 %) girls. The mean age was 11.3 ± 3.09 years. All of the children successfully performed the measurements with two analyzers. The relationship between the means and the differences in the values obtained with NIOX-MINO(R) and NIOX(R) were statistically significant (p < 0.005). In addition, Cohen's Kappa statistic (0.78) suggested a high degree of agreement between the results obtained with the two devices. Conclusions The two analyzers, NIOX-MINO(R) and NIOX(R), were not equivalent. There was good agreement between the FENO values measured with the two devices. Measurement of FENO with the portable electrochemical sensor-based analyzer (NIOX-MINO(R)) is valid and feasible in children older than 5 years

[Diagnostic utility of nocturnal in-home respiratory polygraphy]. / Rentabilidad de la poligrafía respiratoria del sueño realizada en el domicilio.

INTRODUCTION: Sleep apnea-hypopnea syndrome (SAHS) is relatively frequent in children. The gold standard for diagnosis is polysomnography. However, because of technical difficulties and the cost of this method, new alternatives have become available, such as respiratory polygraphy (RP) performed at home or in hospital, which have provided satisfactory results in children with clinical suspicion of SAHS. OBJECTIVE: The aim of this study was to analyze the diagnostic utility of in-home RP in the diagnosis of SAHS in a sample of boys and girls referred to the pediatric respiratory care department for suspected sleep apnea, snoring, or both. MATERIAL AND METHODS: In all patients, a history and physical examination were performed; X-ray of the chest and cavum and RP were carried out. The following qualitative variables were analyzed: place where RP was performed, the result, sex, the reason for consulting, place of residence, results of otorhinolaryngological examination, and treatment. The quantitative variables analyzed were age, total number of apneas, total number of hypopneas, apnea index/hour, hypopnea index/hour, mean and minimum SpxO2, number of snores per hour and the snore index/hour. Statistical analysis was performed using Pearson's chi-square test and Student's t-test. RESULTS: A total of 132 patients were studied, 44 (33.3 %) through in-home RP (group 1) and 88 (66.6 %) through in-hospital RP (group 2). In group 1, two recordings (4.5 %) were considered nonvalid. The mean age of the patients was 8.3 years (SD 3.02). The results [means (standard deviation)] of in-home RP were as follows: apnea-hypopnea index (AHI)/h: 3.4 (4.3); mean SpxO2: 97.3 (1.8); minimum SpxO2: 87.7 (10.3). In group 2, four recordings (4.5 %) were nonvalid. The mean age of the patients was 7.4 years (SD 3). The results of in-hospital RP were as follows: AHI/h: 4.45 (5.4); mean SpxO2: 96.8 (1.8); minimum SpxO2: 87 (11). No significant differences were found between the validity of in-home and in-hospital RP. Likewise, no significant differences were found between AHI/h, SpxO2 and in-home and in-hospital RP. CONCLUSION: In conclusion, in our sample, the diagnostic utility of in-home RP was equal to that of in-hospital RP. In-home RP allows the possibility of performing a more physiological sleep study and, by eliminating the cost of hospitalization, is more cost-efficient. Therefore, in-home RP is a valid and reliable technique for the diagnosis of childhood SAHS.

Rentabilidad de la poligrafía respiratoria del sueño realizada en el domicilio / Diagnostic utility of nocturnal in-home respiratory polygraphy

Introducción El síndrome de apneas-hipopneas del sueño (SAHS) es una entidad relativamente frecuente en niños. La polisomnografía es el patrón oro para el diagnóstico; sin embargo, dada la dificultad técnica y económica para realizarla, han surgido nuevas alternativas como la poligrafía respiratoria hospitalaria (PRH) y domiciliaria (PRD), que en niños con sospecha clínica de SAHS están obteniendo resultados satisfactorios. Objetivo El objetivo de nuestro estudio ha sido analizar en una muestra de niños y niñas, remitidos a consultas de Neumología Infantil por sospecha de apneas del sueño, ronquido o ambos, la rentabilidad de la PRD en el diagnóstico de SAHS. Material y métodos Se ha realizado anamnesis, exploración física, radiografía de tórax y cavum y poligrafía respiratoria (PR) del sueño en todos los casos. Se han analizado las variables cualitativas: lugar de realización, resultado, sexo, motivo de consulta, procedencia, consultas externas de otorrinolaringología (ORL) y tratamiento. Las variables cuantitativas han sido la edad, el número total apneas y de hipopneas, el índice de apneas hora, el índice de hipopneas hora, índice de apneas-hipopneas hora, saturación de oxígeno por pulsioximetría (SpxO2) medio y mínimo, número ronquidos e índice ronquidos hora. Se ha realizado análisis estadístico mediante chi cuadrado de Pearson y la t de Student. Se han estudiado 132 pacientes, 44 de ellos (33,3 %) mediante PRD (grupo 1) y 88 (66,6 %) mediante PRH (grupo 2). En el grupo 1, fueron estudios no válidos 2 (4,5 %) y la edad media fue de 8,3 años (desviación estándar [DE] 3,02). Resultados Los resultados de la PRD en medias y DE fueron: índice de apnea-hipopnea (IAH)/h 3,4 (4,3), SpxO2 media 97,3 (1,8) y SpxO2 mínima 87,7 (10,3). En el grupo 2 fueron estudios no válidos 4 (4,5 %) y la edad media fue de 7,4 años (DE 3). Los resultados de la PRH fueron: IAH/h 4,45 (5,4), SpxO2 media 96,8 (1,8) y SpxO2 mínima 87 (11). No se han encontrado diferencias significativas entre validez de la PR y lugar de realización de la prueba. Así mismo, tampoco se han encontrado diferencias entre edad, IAH/h, SpxO2 y lugar de realización de la PR. Conclusión Podemos decir que en nuestra muestra, la rentabilidad diagnóstica de la poligrafía respiratoria domiciliaria ha sido igual que la hospitalaria. Así mismo, ofrece la posibilidad de realizar un estudio más fisiológico del sueño y ofrece además una mayor rentabilidad económica, al eliminar el coste de hospitalización. Se trataría, por tanto, de una técnica diagnóstica válida y fiable para el diagnóstico de SAHS en la infancia

Introduction Sleep apnea-hypopnea syndrome (SAHS) is relatively frequent in children. The gold standard for diagnosis is polysomnography. However, because of technical difficulties and the cost of this method, new alternatives have become available, such as respiratory polygraphy (RP) performed at home or in hospital, which have provided satisfactory results in children with clinical suspicion of SAHS. Objective The aim of this study was to analyze the diagnostic utility of in-home RP in the diagnosis of SAHS in a sample of boys and girls referred to the pediatric respiratory care department for suspected sleep apnea, snoring, or both. Material and methods In all patients, a history and physical examination were performed; X-ray of the chest and cavum and RP were carried out. The following qualitative variables were analyzed: place where RP was performed, the result, sex, the reason for consulting, place of residence, results of otorhinolaryngological examination, and treatment. The quantitative variables analyzed were age, total number of apneas, total number of hypopneas, apnea index/hour, hypopnea index/hour, mean and minimum SpxO2, number of snores per hour and the snore index/hour. Statistical analysis was performed using Pearson's chi-square test and Student's t-test. Results A total of 132 patients were studied, 44 (33.3 %) through in-home RP (group 1) and 88 (66.6 %) through in-hospital RP (group 2). In group 1, two recordings (4.5 %) were considered nonvalid. The mean age of the patients was 8.3 years (SD 3.02). The results [means (standard deviation)] of in-home RP were as follows: apnea-hypopnea index (AHI)/h: 3.4 (4.3); mean SpxO2: 97.3 (1.8); minimum SpxO2: 87.7 (10.3). In group 2, four recordings (4.5 %) were nonvalid. The mean age of the patients was 7.4 years (SD 3). The results of in-hospital RP were as follows: AHI/h: 4.45 (5.4); mean SpxO2: 96.8 (1.8); minimum SpxO2: 87 (11). No significant differences were found between the validity of in-home and in-hospital RP. Likewise, no significant differences were found between AHI/h, SpxO2 and in-home and in-hospital RP. Conclusion In conclusion, in our sample, the diagnostic utility of in-home RP was equal to that of in-hospital RP. In-home RP allows the possibility of performing a more physiological sleep study and, by eliminating the cost of hospitalization, is more cost-efficient. Therefore, in-home RP is a valid and reliable technique for the diagnosis of childhood SAHS

[Obstructive sleep apnea-hypopnea syndrome]. / Síndrome de apneas-hipopneas obstructivas del sueño.

We analyzed a cohort of 400 patients referred from the otorhinolaryngology department (40.05 %), primary care (PC) (36.52 %), and the pediatric pulmonary unit (17.63 %). The children were referred for clinical suspicion of apneas in 191 (47.87 %), snoring and apneas in 101 (25 %), and snoring in 87 (21.80 %). Adenotonsillar hypertrophy was found in 211 patients (52.75 %), tonsillar hypertrophy in 87 (21.75 %), and adenoid hypertrophy in 73 (18.25 %). All patients underwent respiratory polygraphy (RP) during sleep. Obstructive sleep apnea-hypopnea syndrome (OSAHS) was diagnosed in 298 patients (74.5 %). OSAHS was mild in 96 patients (24 %), moderate in 148 (37 %), and severe in 54 (13.5 %). The results of RP expressed in means plus standard deviation were as follows: number of apneas 21.38 (24.47), number of hypopneas 19.81 (20.74), apnea-hypopnea index per hour (AHI/h) 5.29 (7.10), mean oxygen saturation 94.60 (11.80), minimal saturation 83.14 (13.45), number of snores 98.27 (254.55), and snoring index per hour 5.68 (6.5). Significant differences were found between oxygen saturation and AHI/h per hour. No differences were found among age, mean oxygen saturation, area of residence, reason for consulting, and AHI/h. Adenotonsillectomy was performed in 289 patients (72.25 %) of the initial cohort. In conclusion, OSAHS in childhood is frequent. RP during sleep aids diagnosis. The main cause of OSAHS in children is adenotonsillar hypertrophy.