[Lung function testing and assessment of distal airways in asthma]

[Update on manual bronchial clearance techniques (adults and adolescents)]

In adults and teenagers, airway clearance physiotherapy techniques (ACPT) are various and numerous. However, they for still awaiting scientific validation. Among ACPTs, Slow Expiration with the Glottis Opened in the Lateral Posture (ELTGOL), Autogenic Drainage (DA), and Active Cycling Breathing Technique (ACBT) present a Grade B level of evidence with weak recommendations. Even though these maneuvers are widely applied, precise description of chest physiotherapy (CP) is largely absent from the scientific literature; it is difficult to standardize its implementation and reproduce the results; scientific validation and faithful execution of the techniques are consequently problematic. In this paper, the authors aim to depict each of the three CP techniques as precisely as possible; with this in mind, graphic modeling of the different respiratory exercises is presented in such a way that they can be easily learned, applied and reproduced by physiotherapists.

The 'clinically significant' bronchodilator responsiveness (BDR) in children: a comparative study between six definitions of scholarly societies and a mini-review

Objective: To compare the percentages of children with and without airway obstruction (obstructive and non-obstructive groups, respectively) presenting a 'clinically significant' BDR according to the following definitions: GINA: FEV₁ increase >12% predicted (∆_Predicted), ATS/ERS: FEV₁ increase ≥12% initial (∆_Initial) and ∆FEV₁ absolute (∆) ≥200 ml and/or ∆FVC_Initial ≥12% and ∆FVC ≥200 ml, British thoracic society (BTS): ∆FEV_1Initial ≥12%, National asthma education and prevention program (NAEPP): ∆FEV_1Initial ≥12% and ∆FEV₁ > 200 ml, Group of research on advances in pediatric pneumology: ∆FEV_1Initial ≥12% or ∆PEF_Initial ≥20%, and South African thoracic society (SATS): ∆FEV_1Initial ≥12% or ∆FEV₁ >200 ml and/or ∆FVC_Initial ≥12% or ∆FVC >200 ml.Methods: This was a multicenter comparative study involving 278 children aged 6 to16 years: obstructive group (FEV₁/FVC < lower-limit-of-normal, n = 116) and non-obstructive group (FEV₁/FVC ≥ lower-limit-of-normal, n = 162). Spirometry was performed before/after a bronchodilator test. The Cochrane Q test was used to compare the percentage of responders according to the six definitions.Results: The percentages of responders among the obstructive [ranging from 51.72 (NAEPP) to 74.14% (SATS)] and the non-obstructive [ranging from 0.62 (NAEPP, BTS) to 8.64% (SATS)] groups were definition-dependent.Conclusion: In children, a 'clinically significant' BDR is definition-dependent.

[Small airway diseases and immune deficiency]

INTRODUCTION

Innate or acquired immune deficiency may show respiratory manifestations, often characterized by small airway involvement. The purpose of this article is to provide an overview of small airway disease across the major causes of immune deficiency.

BACKGROUND

In patients with common variable immune deficiency, recurrent lower airway infections may lead to bronchiolitis and bronchiectasis. Follicular and/or granulomatous bronchiolitis of unknown origin may also occur. Bronchiolitis obliterans is the leading cause of death after the first year in patients with lung transplantation. Bronchiolitis obliterans also occurs in patients with allogeneic haematopoietic stem cell transplantation, especially in the context of systemic graft-versus-host disease.

VIEWPOINT AND CONCLUSION

Small airway diseases have different clinical expression and pathophysiology across various causes of immune deficiency. A better understanding of small airways disease pathogenesis in these settings may lead to the development of novel targeted therapies.

[The distal airways in systemic disease]

The association of inflammatory involvement of the distal airways or bronchiolitis and systemic diseases is essentially observed in Sjögren's syndrome, rheumatoid arthritis and chronic inflammatory bowel disease. Bronchiolitis may be mainly cellular in nature, often involving lympho-monocytic cells, and sometimes associated with lymphoid follicles, as in Sjögren's syndrome. It may also, particularly in rheumatoid arthritis, be constrictive, with peribronchiolar fibrosis. This type is associated with a worse prognosis, with possible progression to chronic respiratory insufficiency. The diagnosis of bronchiolitis should be suspected in any atypical form of asthma, or recurrent "bronchitis", and it is essential to look for extrarespiratory symptoms and auto-antibodies to establish the diagnose of systemic disease. The CT appearances coupled with the evaluation of pulmonary function parameters usually lead to the diagnosis. In severe and/or rapidly progressive cases treatment-combining corticosteroids with immunosuppressive drugs may be prescribed, but often with disappointing results. In these cases, lung transplantation should be considered in young patients.

Pulmonary manifestations of Sjögren's syndrome

Sjögren's syndrome is a chronic inflammatory disorder characterized by lymphocytic infiltration of exocrine glands, mainly the lacrimal and salivary glands. However, extraglandular organ systems may frequently be involved, including the lungs. Although subclinical pulmonary inflammation exists in more than 50% of patients, clinically significant pulmonary involvement affects approximately 10% of patients and may be the first manifestation of the disease. The entire respiratory tract may be involved, with a wide spectrum of manifestations including xerotrachea and bronchial sicca, obstructive small airway disease, various patterns of interstitial lung disease, lymphoinfiltrative or lymphoproliferative lung disease, such as lymphoma (usually of MALT type), pulmonary hypertension, pleural involvement, lung cysts, and pulmonary amyloidosis.

Effects of acupuncture-like transcutaneous electrical nerve stimulation on children with asthma

OBJECTIVE

To evaluate the effects of acupuncture-like transcutaneous electrical nerve stimulation (AL-TENS) on children with asthma.

METHODS

After an 8-week run-in period, the experimental group were assigned to treatment with AL-TENS, whereas the control group did not receive AL-TENS. A total of 43 children with asthma were recruited from a hospital and an elementary school. All the cases had been diagnosed as having asthma by physicians. The outcome measures included pulmonary function tests (PFTs), heart rate turbulence (HRT), heart rate variability (HRV), and pediatric asthma quality-of-life questionnaire (PAQLQ).

RESULTS

After 8 weeks of AL-TENS, there were no significant differences on forced vital capacity (FVC), FEV₁/FVC, and peak expiratory flows (PEFs) between the two groups. The HRT is the physiological, biphasic response of the sinus node to premature ventricular contractions. In the experimental group, the mean HRT was statistically significant between pretest and posttest. The HRV and the PAQLQ showed no difference, but in the experimental group, the subscale of the PAQLQ (particularly activity) improved significantly more than the pretest scores. Furthermore, there were no differences in PFTs and HRV after 8 weeks of AL-TENS between the two groups.

CONCLUSIONS

The PAQLQ activities of the experimental group improved significantly more than those of the control group. Reasons may include: 1) the asthma cases were stable and the cases were on stable status and 2) the degree of airway remodeling was less. It is suggested that in the future, treatment frequency and the long-term follow-up for evaluating the effects of AL-TENS on children with asthma should also be considered.