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Januska MN, Goldman DL, Webley W, Teague WG, Cohen RT, Bunyavanich S, Vicencio AG. Bronchoscopy in severe childhood asthma: Irresponsible or irreplaceable? Pediatr Pulmonol 2020; 55:795-802. [PMID: 31730298 PMCID: PMC7385726 DOI: 10.1002/ppul.24569] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/14/2019] [Indexed: 12/13/2022]
Abstract
For children with severe asthma, guideline-based management focuses on the escalation of anti-inflammatory and bronchodilatory medications while addressing comorbid conditions. Bronchoscopy, in this context, has been relegated to ruling out asthma mimickers. More recently, however, there have been questions surrounding the clinical utility of bronchoscopy in severe childhood asthma. In this solicited lecture summary, we discuss the past, present, and potential future applications of bronchoscopy in severe childhood asthma.
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Affiliation(s)
- Megan N. Januska
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY
| | | | | | | | | | - Supinda Bunyavanich
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY
- Ichan School of Medicine at Mount Sinai, Department of Genetics and Genomic Sciences, New York, NY
| | - Alfin G. Vicencio
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY
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2
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Zhang HH, Li CX, Tang LF. The Differential Expression Profiles of miRNA-let 7a, 7b, and 7c in Bronchoalveolar Lavage Fluid From Infants With Asthma and Airway Foreign Bodies. J Evid Based Integr Med 2019; 24:2515690X18821906. [PMID: 30789054 PMCID: PMC6343437 DOI: 10.1177/2515690x18821906] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The aim of this study was to investigate the expression patterns of miRNA-let 7a, 7b, and 7c in bronchoalveolar lavage fluid in infants with asthma and airway foreign bodies. Between January 2016 and February 2017, 27 infants were included and divided into observation group (infants with asthma, n = 15) and control group (infants with airway foreign bodies, n = 12). The differential expression profiles of miRNA-let 7a, 7b, and 7c were determined by reverse transcription–polymerase chain reaction in bronchoalveolar lavage fluid (BALF) from infants of the 2 groups. The BALF was collected from infants undergoing flexible bronchoscopy. MiRNA-let 7a, 7b, and 7c increased significantly in infants from observation group as compared with control group (2.72 ± 0.48 vs 1, 8.23 ± 1.64 vs 1, 3.16 ± 0.62 vs 1, respectively). The increased expression of miRNA-let 7a, 7b, and 7c were associated with the asthma of infants.
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Affiliation(s)
- Hang-Hu Zhang
- 1 The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,2 Shaoxing People's Hospital, Shaoxing, China
| | - Cai-Xue Li
- 1 The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,3 Hangzhou Children's Hospital, Hangzhou, China
| | - Lan-Fang Tang
- 1 The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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3
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Bonato M, Tiné M, Bazzan E, Biondini D, Saetta M, Baraldo S. Early Airway Pathological Changes in Children: New Insights into the Natural History of Wheezing. J Clin Med 2019; 8:jcm8081180. [PMID: 31394827 PMCID: PMC6723918 DOI: 10.3390/jcm8081180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 01/09/2023] Open
Abstract
Asthma is a heterogeneous condition characterized by reversible airflow limitation, with different phenotypes and clinical expressions. Although it is known that asthma is influenced by age, gender, genetic background, and environmental exposure, the natural history of the disease is still incompletely understood. Our current knowledge of the factors determining the evolution from wheezing in early childhood to persistent asthma later in life originates mainly from epidemiological studies. The underlying pathophysiological mechanisms are still poorly understood. The aim of this review is to converge epidemiological and pathological evidence early in the natural history of asthma to gain insight into the mechanisms of disease and their clinical expression.
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Affiliation(s)
- Matteo Bonato
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Mariaenrica Tiné
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Erica Bazzan
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Davide Biondini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Marina Saetta
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy.
| | - Simonetta Baraldo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
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4
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Bourrous M, Lahmini W, Nouri H, Haimeur N. Subcutaneous emphysema and pneumomediastinum in child with asthma revealing occult foreign body aspiration: a case report. J Med Case Rep 2019; 13:157. [PMID: 31128595 PMCID: PMC6535189 DOI: 10.1186/s13256-019-2076-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 04/09/2019] [Indexed: 11/15/2022] Open
Abstract
Background Exacerbations of asthma constitute the most common cause of pneumomediastinum and subcutaneous emphysema in children. Foreign body aspiration is a rare cause of pneumomediastinum and subcutaneous emphysema. Foreign body aspiration leading to the occurrence of pneumomediastinum in a child with asthma may go unnoticed and be wrongly attributed to asthma, which leads to delayed diagnosis as well as to life-threatening and long-term complications. Case presentation We describe a case of a 6-year-old Moroccan boy with asthma who was admitted to our emergency department for acute dyspnea and persistent dry cough. The patient was initially treated as having acute asthma exacerbation. Owing to insufficient clinical and radiographic improvement with asthma treatment, a rigid bronchoscopy under general anesthesia was performed. A pumpkin seed was removed from the left main bronchus. Clinical and radiographic improvement was achieved after foreign body extraction. Conclusions This case emphasizes that the possibility of foreign body aspiration should always and carefully be considered by the emergency physician when faced with a child with asthma presenting with pneumomediastinum and subcutaneous emphysema as an important differential diagnosis even in the absence of a history of foreign body aspiration.
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Affiliation(s)
- Mounir Bourrous
- Department of Paediatric Emergency, UHC Mohamed VI, Cadi Ayyad University, Faculty of medicine and pharmacy, PO Box: 7010, Sidi Abbad Street, 40000, Marrakech, Morocco.
| | - Widad Lahmini
- Department of Paediatric Emergency, UHC Mohamed VI, Cadi Ayyad University, Faculty of medicine and pharmacy, PO Box: 7010, Sidi Abbad Street, 40000, Marrakech, Morocco
| | - Hassan Nouri
- Department of ORL, UHC Mohamed VI, Cadi Ayyad University, Marrakech, Morocco
| | - Nouzha Haimeur
- Department of Anesthesia and Critical Care, UHC Mohamed VI, Cadi Ayyad University, Marrakech, Morocco
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5
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Shah SP, Grunwell J, Shih J, Stephenson S, Fitzpatrick AM. Exploring the Utility of Noninvasive Type 2 Inflammatory Markers for Prediction of Severe Asthma Exacerbations in Children and Adolescents. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2624-2633.e2. [PMID: 31100552 DOI: 10.1016/j.jaip.2019.04.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Noninvasive markers of type 2 inflammation are needed to identify children and adolescents who might benefit from personalized biologic therapy. OBJECTIVE We hypothesized that blood eosinophil counts would predict 1 or more acute visits for asthma and that prediction could be improved with the addition of a second, noninvasive type 2 inflammatory biomarker. METHODS Children and adolescents 5 to 21 years (N = 589) with an asthma exacerbation necessitating systemic corticosteroid treatment in the previous year completed a characterization visit and telephone calls at 6 and 12 months. The primary outcome was an acute visit for asthma with receipt of systemic corticosteroids. Acute visits were verified by medical record review. Exploratory outcomes included time to first acute visit and hospitalization. RESULTS Acute visits occurred in 106 (35.5%) children and 72 (24.8%) adolescents. Elevated blood eosinophils were associated with increased odds and shorter time to first acute visit, but optimal cut-points differed by age (≥150 vs ≥300 cells/μL for children vs adolescents, respectively). The addition of a second marker of type 2 inflammation did not improve prediction in children, but increased the odds and hazard of an acute visit up to 16.2% and 11.9%, respectively, in adolescents. Similar trends were noted for hospitalizations. CONCLUSIONS Blood eosinophils and other noninvasive markers of type 2 inflammation may be useful in the clinical assessment of children and adolescents with asthma. However, features of type 2 inflammation vary by age. Whether children and adolescents also respond differently to management of type 2 inflammation is unclear and warrants further evaluation.
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Affiliation(s)
- Samar P Shah
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jocelyn Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer Shih
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga.
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6
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Teague WG, Lawrence MG, Shirley DAT, Garrod AS, Early SV, Payne JB, Wisniewski JA, Heymann PW, Daniero JJ, Steinke JW, Froh DK, Braciale TJ, Ellwood M, Harris D, Borish L. Lung Lavage Granulocyte Patterns and Clinical Phenotypes in Children with Severe, Therapy-Resistant Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1803-1812.e10. [PMID: 30654199 DOI: 10.1016/j.jaip.2018.12.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 12/29/2018] [Accepted: 12/31/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Children with severe asthma have frequent exacerbations despite guidelines-based treatment with high-dose corticosteroids. The importance of refractory lung inflammation and infectious species as factors contributing to poorly controlled asthma in children is poorly understood. OBJECTIVE To identify prevalent granulocyte patterns and potential pathogens as targets for revised treatment, 126 children with severe asthma underwent clinically indicated bronchoscopy. METHODS Diagnostic tests included bronchoalveolar lavage (BAL) for cell count and differential, bacterial and viral studies, spirometry, and measurements of blood eosinophils, total IgE, and allergen-specific IgE. Outcomes were compared among 4 BAL granulocyte patterns. RESULTS Pauci-granulocytic BAL was the most prevalent granulocyte category (52%), and children with pauci-granulocytic BAL had less postbronchodilator airflow limitation, less blood eosinophilia, and less detection of BAL enterovirus compared with children with mixed granulocytic BAL. Children with isolated neutrophilia BAL were differentiated by less blood eosinophilia than those with mixed granulocytic BAL, but greater prevalence of potential bacterial pathogens compared with those with pauci-granulocytic BAL. Children with isolated eosinophilia BAL had features similar to those with mixed granulocytic BAL. Children with mixed granulocytic BAL took more maintenance prednisone, and had greater blood eosinophilia and allergen sensitization compared with those with pauci-granulocytic BAL. CONCLUSIONS In children with severe, therapy-resistant asthma, BAL granulocyte patterns and infectious species are associated with novel phenotypic features that can inform pathway-specific revisions in treatment. In 32% of children evaluated, BAL revealed corticosteroid-refractory eosinophilic infiltration amenable to anti-TH2 biological therapies, and in 12%, a treatable bacterial pathogen.
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Affiliation(s)
- W Gerald Teague
- Child Health Research Center, Division of Respiratory Medicine, Allergy, and Immunology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va.
| | - Monica G Lawrence
- Division of Allergy, Asthma, and Immunology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Debbie-Ann T Shirley
- Child Health Research Center, Division of Respiratory Medicine, Allergy, and Immunology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - Andrea S Garrod
- Child Health Research Center, Division of Respiratory Medicine, Allergy, and Immunology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - Stephen V Early
- Department of Otolaryngology, Head and Neck Surgery, University of Virginia School of Medicine, Charlottesville, Va
| | - Jackie B Payne
- Child Health Research Center, Division of Respiratory Medicine, Allergy, and Immunology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - Julia A Wisniewski
- Child Health Research Center, Division of Respiratory Medicine, Allergy, and Immunology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - Peter W Heymann
- Child Health Research Center, Division of Respiratory Medicine, Allergy, and Immunology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - James J Daniero
- Department of Otolaryngology, Head and Neck Surgery, University of Virginia School of Medicine, Charlottesville, Va
| | - John W Steinke
- Division of Allergy, Asthma, and Immunology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Deborah K Froh
- Child Health Research Center, Division of Respiratory Medicine, Allergy, and Immunology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - Thomas J Braciale
- Beirne Carter Immunology Center, University of Virginia School of Medicine, Charlottesville, Va
| | - Michael Ellwood
- University Physicians Group, University of Virginia School of Medicine, Charlottesville, Va
| | - Drew Harris
- Division of Respiratory and Critical Care Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Larry Borish
- Division of Allergy, Asthma, and Immunology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va; Beirne Carter Immunology Center, University of Virginia School of Medicine, Charlottesville, Va; Department of Microbiology, University of Virginia School of Medicine, Charlottesville, Va
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7
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Erkman J, Vaynblat A, Thomas K, Segal LN, Levine J, Moy L, Greifer M, Giusti R, Shah R, Kazachkov M. Airway and esophageal eosinophils in children with severe uncontrolled asthma. Pediatr Pulmonol 2018; 53:1598-1603. [PMID: 30353711 DOI: 10.1002/ppul.24180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 09/21/2018] [Indexed: 12/14/2022]
Abstract
AIM Children with severe uncontrolled asthma (SUA) have a high burden of symptoms and increased frequency of asthma exacerbations. Reflux esophagitis and eosinophilic esophagitis are important co-morbid factors for SUA. Both are associated with the presence of eosinophils in esophageal mucosa. We hypothesized that esophageal eosinophils are frequently present and correlate with the presence of airway eosinophils in children with SUA. METHOD We performed a retrospective analysis of a prospective database of children who underwent "triple endoscopy" (sleep laryngoscopy, bronchoscopy with bronchoalveolar lavage [BAL] and endobronchial biopsy [EBB], and esophagogastroduodenoscopy with esophageal biopsy [EsB]) at our Aerodigestive Center for evaluation of SUA. Children with known cystic fibrosis, primary ciliary dyskinesia, and aspiration-related lung disease were excluded. RESULT Twenty-four children (21 males) ages 2-16 years were studied. Elevated BAL eosinophils were found in 10 (42%) patients, endobronchial eosinophils in 16 (67%); 7 (29%) had endobronchial eosinophils without elevated BAL eosinophils. Esophageal eosinophils were found in 11 (46%) patients. There was a correlation between the amount of eosinophils in BAL and EBB (R = 0.43, P = 0.05) airway eosinophils, defined as elevated BAL and/or EBB eosinophils, correlated with esophageal eosinophils (R = 0.41, P = 0.047). CONCLUSION We concluded that airway and esophageal eosinophils are frequently present in children with SUA.
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Affiliation(s)
- Jessica Erkman
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
| | - Allen Vaynblat
- Department of Cardiothoracic Surgery, NYU Langone Health, New York
| | | | - Leopoldo N Segal
- Department of Medicine, Division of Pulmonology, Critical Care and Sleep Medicine, NYU Langone Health, New York
| | - Jeremiah Levine
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
| | - Libia Moy
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
| | - Melanie Greifer
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
| | - Robert Giusti
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
| | - Rasik Shah
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
| | - Mikhail Kazachkov
- Aerodigestive Center, Hassenfeld Children's Hospital, NYU Langone Health, New York
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8
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Carlens J, Fuge J, Price T, DeLuca DS, Price M, Hansen G, Schwerk N. Complications and risk factors in pediatric bronchoscopy in a tertiary pediatric respiratory center. Pediatr Pulmonol 2018; 53:619-627. [PMID: 29393584 DOI: 10.1002/ppul.23957] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 01/08/2018] [Indexed: 11/09/2022]
Abstract
UNLABELLED Bronchoscopy is an established procedure routinely used by pediatric pulmonologists. Despite its frequent application, data on complications and specific risk factors are scarce and sometimes conflicting. AIM The aim of this study was to evaluate frequency and severity of clearly defined complications of bronchoscopy in children that occur both during and after the procedure, and to identify potential risk factors. METHOD A retrospective single-center analysis of 670 elective bronchoscopies in 522 children aged 0-17 years during the time period of 2008-2012 was performed. Procedures in intensive care unit patients and children after lung transplantation were excluded. RESULTS Mean patient age was 5.58 years, 61.5% had underlying chronic diseases. Intraprocedural complications occurred in 7.2% of all procedures; of these, hypoxemia was the most common, occuring in 4.8% of cases. Postprocedural adverse events were documented in 25.8%, the most frequent of which were fever in 14.2% and transient oxygen dependency in 13.4% of cases. No bronchoscopy related deaths occurred. Multivariate logistic regression was used to identify risk factors for (1) any complication, or (2) severe complications. Age below two years (OR 1.837 [1.224-2.757], P = 0.003) and primary ciliary dyskinesia (OR 4.821 [2.018-11.552], P < 0.001) significantly contributed to risk of any complication. Age below 2 years (OR 2.478 [1.072-5.728], P = 0.034) and underlying cardiovascular disease (OR 2.678 [1.013-7.077], P = 0.047) were independent risk factors for severe complications. CONCLUSION Bronchoscopy in children is relatively safe. Nevertheless, adverse events can occur and knowledge of risk factors may help prevent complications.
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Affiliation(s)
- Julia Carlens
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease, (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Timothy Price
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - David S DeLuca
- Biomedical Research in Endstage and Obstructive Lung Disease, (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Mareike Price
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Gesine Hansen
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease, (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Nicolaus Schwerk
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease, (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
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9
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Boesch RP, Baughn JM, Cofer SA, Balakrishnan K. Trans-nasal flexible bronchoscopy in wheezing children: Diagnostic yield, impact on therapy, and prevalence of laryngeal cleft. Pediatr Pulmonol 2018; 53:310-315. [PMID: 28910519 DOI: 10.1002/ppul.23829] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/22/2017] [Indexed: 11/07/2022]
Abstract
AIM Persistent or recurrent wheezing is a common indication for flexible bronchoscopy, as anatomic and infectious or inflammatory changes are highly prevalent. We sought to evaluate the prevalence of anatomic, infectious, and inflammatory disease in a cohort of children undergoing flexible bronchoscopy for wheezing or poorly controlled asthma. METHODS We retrospectively reviewed all children <18 years old who underwent flexible bronchoscopy at our center from October 29, 2012-December 31, 2016 for the primary or secondary indication of wheezing (persistent, frequently recurring, or atypical) or poorly controlled asthma. RESULTS A total of 101 procedures were identified in 94 patients, aged 3 months to 18 years. Potential anatomic causes for wheezing identified in 45.7% of patients and inflammatory changes in 49.5% of procedures. This included the identification of a laryngeal cleft in 17% for which half required medical or surgical management. Tracheobronchomalacia was the most commonly identified anatomic lesion. Thirty children from this cohort had poorly controlled asthma. Among this subgroup, 54% had increased neutrophils on BAL and 30% had an anatomic contributor to wheezing, including one with a laryngeal cleft. Based on findings from flexible bronchoscopy, management changes made in 63.8% of patients. This included medication changes in 54 and surgical intervention in 9. DISCUSSION We conclude that transnasal flexible bronchoscopy has high yield in children with recurrent, persistent, or atypical wheezing and those with poorly controlled asthma. Laryngeal cleft has a reasonably high prevalence that warrants specific evaluation in this population.
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Affiliation(s)
- Richard P Boesch
- Mayo Clinic Children's Center, Division of Pediatric Pulmonology, Rochester, Minnesota
| | - Julie M Baughn
- Mayo Clinic Children's Center, Division of Pediatric Pulmonology, Rochester, Minnesota
| | - Shelagh A Cofer
- Mayo Clinic Minnesota, Department of Otorhinolaryngology-Head and Neck Surgery, Rochester, Minnesota
| | - Karthik Balakrishnan
- Mayo Clinic Minnesota, Department of Otorhinolaryngology-Head and Neck Surgery, Rochester, Minnesota
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10
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Akcora B, Celikkaya ME, Ozer C. Bronchoscopy for foreign body aspiration and effects of nebulized albuterol and budesonide combination. Pak J Med Sci 2017; 33:81-85. [PMID: 28367177 PMCID: PMC5368335 DOI: 10.12669/pjms.331.11297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective: A foreign body aspiration in the tracheobronchial tree is a dangerous medical condition in the childhood period. Although rigid bronchoscopy is a safe procedure, it may cause complications. The aim of this study was to present our bronchoscopy experience and to evaluate the efficacy of pre-operative administration of nebulized albuterol and budesonide combination for reducing intra-operative complications in foreign body aspirated cases. Methods: In this retrospective study our pediatric cases in which a foreign body was removed from tracheobronchial tree in last 8 years were analyzed. After excluding the patients who needed emergent and negative bronchoscopies, the remaining clinically stable 84 patients were compared for the effects of preoperative administration of nebulized albuterol and budesonide combination on bronchoscopy complications. Results: There were 51 boys (60.3%) and 33 girls (39.7%). There were 38 children in the non-nebulized group and 46 children in the nebulized group. We found that the combined albuterol and budesonide nebulization decrease complications such as arterial oxygen desaturation (p<0.05), and bronchospasm (p<0.05) during the bronchoscopic intervention. Conclusion: Preoperative nebulization of albuterol and budesonide combination may decrease perioperative complications of bronchoscopy.
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Affiliation(s)
- Bulent Akcora
- Bulent Akcora, MD, Associate Professor, School of Medicine, Department of Pediatric Surgery, Mustafa Kemal University, 31124, Antakya, Hatay, Turkey
| | - Mehmet Emin Celikkaya
- Mehmet Emin Celikkaya, MD, School of Medicine, Department of Pediatric Surgery, Mustafa Kemal University, 31124, Antakya, Hatay, Turkey
| | - Cahit Ozer
- Cahit Ozer, MD, Professor, School of Medicine, Department of Family Medicine, Mustafa Kemal University, 31124, Antakya, Hatay, Turkey
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11
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Lezmi G, Gosset P, Deschildre A, Abou-Taam R, Mahut B, Beydon N, de Blic J. Airway Remodeling in Preschool Children with Severe Recurrent Wheeze. Am J Respir Crit Care Med 2015; 192:164-71. [PMID: 25961111 DOI: 10.1164/rccm.201411-1958oc] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
RATIONALE Airway wall structure in preschoolers with severe recurrent wheeze is poorly described. OBJECTIVES To describe airway wall structure and inflammation in preschoolers with severe recurrent wheeze. METHODS Flexible bronchoscopy was performed in two groups of preschoolers with severe recurrent wheeze: group 1, less than or equal to 36 months (n = 20); group 2, 36-59 months (n = 29). We assessed airway inflammation, reticular basement membrane (RBM) thickness, airway smooth muscle (ASM), mucus gland area, vascularity, and epithelial integrity. Comparisons were then made with biopsies from 21 previously described schoolchildren with severe asthma (group 3, 5-11.2 yr). MEASUREMENTS AND MAIN RESULTS RBM thickness was lower in group 1 than in group 2 (3.3 vs. 3.9 μm; P = 0.02), was correlated with age (P < 0.01; ρ = 0.62), and was higher in schoolchildren than in preschoolers (6.8 vs. 3.8 μm; P < 0.01). ASM area was lower in preschoolers than in schoolchildren (9.8% vs. 16.5%; P < 0.01). Vascularity was higher in group 1 than in group 2 (P = 0.02) and group 3 (P < 0.05). Mucus gland area was higher in preschoolers than in schoolchildren (16.4% vs. 4.6%; P < 0.01). Inflammatory cell counts in biopsies were not correlated with airway wall structure. ASM area was higher in preschoolers with atopy than without atopy (13.1% vs. 7.7%; P = 0.01). Airway morphometrics and inflammation were similar in viral and multiple-trigger wheezers. CONCLUSIONS In preschoolers with severe recurrent wheeze, markers of remodeling and inflammation are unrelated, and atopy is associated with ASM. In the absence of control subjects, we cannot determine whether differences observed in RBM thickness and vascularity result from disease or normal age-related development.
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Affiliation(s)
- Guillaume Lezmi
- 1 AP-HP, Hôpital Necker-Enfants Malades, Service de Pneumologie et d'Allergologie Pédiatriques, Paris, France.,2 Université Paris Descartes, Paris, France
| | - Philippe Gosset
- 3 Institut Pasteur de Lille, Centre d'Infection et d'Immunité de Lille, Lille, France.,4 Université Lille Nord de France, Lille, France.,5 Centre National de la Recherche Scientifique, UMR 8204, Lille, France.,6 Institut National de la Santé et de la Recherche Médicale, U1019, Lille, France.,7 Institut Fédératif de la Recherche 142, Lille, France
| | - Antoine Deschildre
- 8 Unité de Pneumologie-Allergologie Pédiatrique, Clinique de Pédiatrie Jeanne de Flandre, CHRU de Lille, Université Nord de France, Lille, France
| | - Rola Abou-Taam
- 1 AP-HP, Hôpital Necker-Enfants Malades, Service de Pneumologie et d'Allergologie Pédiatriques, Paris, France
| | | | - Nicole Beydon
- 10 APHP, Hôpital Armand Trousseau, Service d'Explorations Fonctionnelles Respiratoires, Paris, France
| | - Jacques de Blic
- 1 AP-HP, Hôpital Necker-Enfants Malades, Service de Pneumologie et d'Allergologie Pédiatriques, Paris, France.,2 Université Paris Descartes, Paris, France
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12
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van Mastrigt E, Vanlaeken L, Heida F, Caudri D, de Jongste JC, Timens W, Rottier BL, Krijger RRD, Pijnenburg MW. The clinical utility of reticular basement membrane thickness measurements in asthmatic children. J Asthma 2015; 52:926-30. [PMID: 26367334 DOI: 10.3109/02770903.2015.1025409] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Reticular basement membrane (RBM) thickness is one of the pathological features of asthma and can be measured in endobronchial biopsies. We assessed the feasibility of endobronchial biopsies in a routine clinical setting and investigated the clinical value of RBM thickness measurements for asthma diagnosis in children. METHODS We included all children who underwent bronchoscopy with endobronchial mucosal biopsies for clinical reasons and divided them into three subgroups: (1) no asthma, (2) mild-moderate asthma, and (3) problematic severe asthma. RESULTS In 152/214 (71%) patients, mean age 9.5 years (SD 4.6; range 0.1-18.7) adequate biopsies were retrieved in which RBM thickness could be measured. Mean (SD) RBM thickness differed significantly among children without asthma, with mild-moderate asthma, and with problematic severe asthma (p = 0.04), 4.68 (1.24) µm, 4.56 (0.89) µm, and 5.21 (1.10) µm respectively. This difference disappeared after adding exhaled nitric oxide to the multivariate model. CONCLUSIONS This study confirms the difference in RBM thickness between children with and without asthma and between asthma severities in a routine clinical care setting. However, quantifying the RBM thickness appeared to have no added clinical diagnostic value for asthma in children.
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Affiliation(s)
- Esther van Mastrigt
- a Department of Pediatric Pulmonology, Erasmus Medical Centre , Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Leonie Vanlaeken
- a Department of Pediatric Pulmonology, Erasmus Medical Centre , Sophia Children's Hospital , Rotterdam , The Netherlands .,b Department of Pathology , Erasmus Medical Centre , Rotterdam , The Netherlands
| | - Fardou Heida
- c Department of Pathology and Medical Biology , University of Groningen, University Medical Centre Groningen , Groningen , The Netherlands , and.,d Department of Pediatric Pulmonology , University of Groningen, University Medical Centre, Beatrix Children's Hospital , Groningen , The Netherlands
| | - Daan Caudri
- a Department of Pediatric Pulmonology, Erasmus Medical Centre , Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Johan C de Jongste
- a Department of Pediatric Pulmonology, Erasmus Medical Centre , Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Wim Timens
- c Department of Pathology and Medical Biology , University of Groningen, University Medical Centre Groningen , Groningen , The Netherlands , and
| | - Bart L Rottier
- d Department of Pediatric Pulmonology , University of Groningen, University Medical Centre, Beatrix Children's Hospital , Groningen , The Netherlands
| | - Ronald R de Krijger
- b Department of Pathology , Erasmus Medical Centre , Rotterdam , The Netherlands
| | - Mariëlle W Pijnenburg
- a Department of Pediatric Pulmonology, Erasmus Medical Centre , Sophia Children's Hospital , Rotterdam , The Netherlands
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13
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Doberer D, Trejo Bittar HE, Wenzel SE. Should lung biopsies be performed in patients with severe asthma? Eur Respir Rev 2015; 24:525-39. [PMID: 26324815 PMCID: PMC9487699 DOI: 10.1183/16000617.0045-2015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Asthma, and severe asthma, in particular, is increasingly recognised as a heterogeneous disease. Identifying these different phenotypes of asthma and assigning patients to phenotype-specific treatments is one of the current conundrums in respiratory medicine. Any diagnostic procedure in severe asthma (or any disease) should have two aims: 1) better understanding or identifying the diagnosis, and 2) providing information on the heterogeneity of asthma phenotypes to guide therapy with the objective of improving outcomes. Lung biopsies can target the large and small airways as well as the lung parenchyma. All compartments are affected in severe asthma; however, knowledge on the distal lung is limited. At this point, it remains uncertain whether lung specimens routinely add diagnostic information that is unable to be obtained otherwise. Indeed, whether a lung biopsy is indicated in the workup of a patient with severe asthma remains an individual decision. It is hoped this review will support rational decision-making and provide a detailed synopsis of the varied histopathological features seen in biopsies of patients with a diagnosis of severe asthma. Due to limited data on this topic this review is primarily based on opinion with recommendations arising primarily from the personal experience of the authors.
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Affiliation(s)
- Daniel Doberer
- University of Pittsburgh Asthma Institute at UPMC, Pittsburgh, PA, USA,Dept of Internal and Pulmonary Medicine, Wilhelminenspital Wien, Medical University of Vienna, Vienna, Austria,Daniel Doberer, Dept of Internal and Pulmonary Medicine, Wilhelminenspital, Montleartstrasse 37, 1160 Vienna, Austria. E-mail:
| | | | - Sally E. Wenzel
- University of Pittsburgh Asthma Institute at UPMC, Pittsburgh, PA, USA
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14
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Abstract
The incidence of anaphylaxis during anesthesia has been reported to range from 1 in 4000 to 1 in 25,000. Anaphylaxis during anesthesia can present as cardiovascular collapse, airway obstruction, and/or skin manifestation. It can be difficult to differentiate between immune and nonimmune mast cell-mediated reactions and pharmacologic effects from the variety of medications administered during general anesthesia. In addition, cutaneous manifestations of anaphylaxis are less likely to be apparent when anaphylaxis occurs in this setting. The evaluation of IgE-mediated reactions to medications used during anesthesia can include skin testing to a variety of anesthetic agents. Specifically, thiopental allergy has been documented by skin tests. Neuromuscular blocking agents such as succinylcholine can cause nonimmunologic histamine release, but there have also been reports of IgE-mediated reactions in some patients. Reactions to opioid analgesics are usually caused by direct mast cell mediator release rather than IgE-dependent mechanisms. Antibiotics that are administered perioperatively can cause immunologic or nonimmunologic reactions. Protamine can cause severe systemic reactions through IgE-mediated or nonimmunologic mechanisms. Blood transfusions can elicit a variety of systemic reactions, some of which might be IgE-mediated or mediated through other immunologic mechanisms. The management of anaphylactic reactions that occur during general anesthesia is similar to the management of anaphylaxis in other situations.
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Affiliation(s)
- Shrikant Mali
- MDS Oral and Maxillofacial Surgery, Sr Lecturer, Department of Oral and Maxillofacial Surgery CSMSS Dental College, Aurangabad, India
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15
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Vogt B, Falkenberg C, Weiler N, Frerichs I. Pulmonary function testing in children and infants. Physiol Meas 2014; 35:R59-90. [PMID: 24557323 DOI: 10.1088/0967-3334/35/3/r59] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Pulmonary function testing is performed in children and infants with the aim of documenting lung development with age and making diagnoses of lung diseases. In children and infants with an established lung disease, pulmonary function is tested to assess the disease progression and the efficacy of therapy. It is difficult to carry out the measurements in this age group without disturbances, so obtaining results of good quality and reproducibility is challenging. Young children are often uncooperative during the examinations. This is partly related to their young age but also due to the long testing duration and the unpopular equipment. We address a variety of examination techniques for lung function assessment in children and infants in this review. We describe the measuring principles, examination procedures, clinical findings and their interpretation, as well as advantages and limitations of these methods. The comparability between devices and centres as well as the availability of reference values are still considered a challenge in many of these techniques. In recent years, new technologies have emerged allowing the assessment of lung function not only on the global level but also on the regional level. This opens new possibilities for detecting regional lung function heterogeneity that might lead to a better understanding of respiratory pathophysiology in children.
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Affiliation(s)
- B Vogt
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Kiel, Germany
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16
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Gupta A, Dimeloe S, Richards DF, Chambers ES, Black C, Urry Z, Ryanna K, Xystrakis E, Bush A, Saglani S, Hawrylowicz CM. Defective IL-10 expression and in vitro steroid-induced IL-17A in paediatric severe therapy-resistant asthma. Thorax 2013; 69:508-15. [PMID: 24347461 DOI: 10.1136/thoraxjnl-2013-203421] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Understanding of immune mechanisms underpinning asthma has emerged from studies in adults. It is increasingly recognised, both immunologically and in the development of novel therapies, that adult responses cannot be used accurately to predict those of children. METHODS Using a well-defined paediatric cohort of severe therapy-resistant asthma (STRA) patients, we investigated cytokine profiles in the airway by analysis of bronchoalveolar lavage fluid. The in vitro capacity of peripheral blood mononuclear cells (PBMCs) for cytokine production was also assessed following polyclonal T cell activation in culture, in the absence or presence of dexamethasone and 1α,25-dihydroxyvitamin D3. RESULTS Children with both moderate and STRA had significantly diminished levels of anti-inflammatory interleukin (IL)-10 in airway lavage samples when compared with non-asthmatic controls (p<0.001). Their PBMCs also demonstrated significantly impaired capacity to secrete IL-10 in culture (p<0.001). Dexamethasone regulated the balance between PBMC IL-10 and IL-13 production, increasing IL-10 secretion (p<0.001) and decreasing IL-13 (p<0.001) but unexpectedly enhanced IL-17A production in all groups-most strikingly in the STRA cohort (p<0.001). The inclusion of the active form of vitamin D, 1α,25-dihydroxyvitamin D3, in culture enhanced dexamethasone-induced IL-10 (p<0.05) without marked effects on IL-13 or IL-17A production. Furthermore, systemic vitamin D status directly correlated with airway IL-10 (r=0.6, p<0.01). CONCLUSIONS These findings demonstrate reduced peripheral and local IL-10 synthesis in paediatric asthma, and support therapeutic augmentation of low circulating vitamin D in severe, difficult-to-treat asthma, in order to correct impaired IL-10 levels. Conversely, steroids enhanced IL-17A levels, and therefore any steroid-sparing properties of vitamin D may have additional benefit in STRA.
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Affiliation(s)
- Atul Gupta
- MRC & Asthma UK Centre for Allergic Mechanisms of Asthma, King's College London, Guy's Hospital, London, UK Department of Pediatric Respiratory Medicine, Imperial College London, London, UK
| | - Sarah Dimeloe
- MRC & Asthma UK Centre for Allergic Mechanisms of Asthma, King's College London, Guy's Hospital, London, UK
| | - David F Richards
- MRC & Asthma UK Centre for Allergic Mechanisms of Asthma, King's College London, Guy's Hospital, London, UK
| | - Emma S Chambers
- MRC & Asthma UK Centre for Allergic Mechanisms of Asthma, King's College London, Guy's Hospital, London, UK
| | - Cheryl Black
- MRC & Asthma UK Centre for Allergic Mechanisms of Asthma, King's College London, Guy's Hospital, London, UK
| | - Zoe Urry
- MRC & Asthma UK Centre for Allergic Mechanisms of Asthma, King's College London, Guy's Hospital, London, UK
| | - Kimuli Ryanna
- MRC & Asthma UK Centre for Allergic Mechanisms of Asthma, King's College London, Guy's Hospital, London, UK
| | - Emmanuel Xystrakis
- MRC & Asthma UK Centre for Allergic Mechanisms of Asthma, King's College London, Guy's Hospital, London, UK
| | - Andrew Bush
- MRC & Asthma UK Centre for Allergic Mechanisms of Asthma, King's College London, Guy's Hospital, London, UK Department of Pediatric Respiratory Medicine, Imperial College London, London, UK
| | - Sejal Saglani
- MRC & Asthma UK Centre for Allergic Mechanisms of Asthma, King's College London, Guy's Hospital, London, UK Department of Pediatric Respiratory Medicine, Imperial College London, London, UK
| | - Catherine M Hawrylowicz
- MRC & Asthma UK Centre for Allergic Mechanisms of Asthma, King's College London, Guy's Hospital, London, UK
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Vijverberg SJH, Hilvering B, Raaijmakers JAM, Lammers JWJ, Maitland-van der Zee AH, Koenderman L. Clinical utility of asthma biomarkers: from bench to bedside. Biologics 2013; 7:199-210. [PMID: 24009412 PMCID: PMC3762671 DOI: 10.2147/btt.s29976] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Asthma is a chronic disease characterized by airway inflammation, bronchial hyperresponsiveness, and recurrent episodes of reversible airway obstruction. The disease is very heterogeneous in onset, course, and response to treatment, and seems to encompass a broad collection of heterogeneous disease subtypes with different underlying pathophysiological mechanisms. There is a strong need for easily interpreted clinical biomarkers to assess the nature and severity of the disease. Currently available biomarkers for clinical practice - for example markers in bronchial lavage, bronchial biopsies, sputum, or fraction of exhaled nitric oxide (FeNO) - are limited due to invasiveness or lack of specificity. The assessment of markers in peripheral blood might be a good alternative to study airway inflammation more specifically, compared to FeNO, and in a less invasive manner, compared to bronchoalveolar lavage, biopsies, or sputum induction. In addition, promising novel biomarkers are discovered in the field of breath metabolomics (eg, volatile organic compounds) and (pharmaco)genomics. Biomarker research in asthma is increasingly shifting from the assessment of the value of single biomarkers to multidimensional approaches in which the clinical value of a combination of various markers is studied. This could eventually lead to the development of a clinically applicable algorithm composed of various markers and clinical features to phenotype asthma and improve diagnosis and asthma management.
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Affiliation(s)
- Susanne JH Vijverberg
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Bart Hilvering
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jan AM Raaijmakers
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Jan-Willem J Lammers
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Anke-Hilse Maitland-van der Zee
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Leo Koenderman
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
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18
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dos Santos ABG, Binoki D, Silva LFF, de Araujo BB, Otter ID, Annoni R, Tsokos M, Stein RT, Hiemstra PS, Rabe KF, Debertin A, Tschernig T, Mauad T. Immune cell profile in infants' lung tissue. Ann Anat 2013; 195:596-604. [PMID: 23856415 DOI: 10.1016/j.aanat.2013.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/30/2013] [Accepted: 05/06/2013] [Indexed: 12/29/2022]
Abstract
Little is known about the normal immune cell profile in the lungs of infants without pulmonary disease. Normal lung samples obtained at autopsy of 10 infants that died either due to incidental or inflicted causes or non-pulmonary diseases were stained for antibodies against B and T lymphocytes, macrophages, NK cells, cytotoxic cells, dendritic cells and mast cells. Cells were quantified in the airway epithelial layer, inner layer (between the epithelium and the outer smooth muscle border), outer layer (between the outer smooth muscle border and the external limits of the airway) and alveolar septa. Basement membrane or alveolar septa lengths were assessed by image analysis. Results were expressed as cells/mm. The median age of patients was 6.8 months, ranging from 11 to 840 days. The inner layer of the airways was the region with the smallest density of cells. There was a predominance of cells related to the innate immunity such as CD56+, Granzyme B+ and CD68+ cells in the epithelial layer and alveolar parenchyma. The outer layer and the lung parenchyma presented the highest cellular density. There were very few CD4+ T cells or dendritic cells in most of the lung compartments. The numbers of CD3+ T and granzyme B+ cells correlated positively with age. There was a compartmentalization of immune cells along airways and parenchyma, which may be related to the development of innate and acquired lung defense mechanisms.
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19
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Behrmann J. The paucity of ethical analysis in allergology. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2013; 9:5. [PMID: 23388345 PMCID: PMC3573914 DOI: 10.1186/1710-1492-9-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 01/17/2013] [Indexed: 11/10/2022]
Abstract
While a growing body of research is uncovering the aetiology and effective treatments for allergy, research that assess the broader ethical implications of this disease is lacking significantly. This article will demonstrate both the paucity of academic research concerning ethical implications in allergy and explain why ethical analysis is integral to formulating effective health strategies for allergic disease. An exhaustive literature search of publications in French and English identified less than 35 academic articles focussed on the topic of ethics and allergy; this is a miniscule number when compared to the amount of articles published on ethical issues related to other chronic illnesses, such as obesity. It is important to demonstrate to allergy specialists the need for, and utility of, further incorporating ethical analyses in allergology; the current success of Ethical, Legal, Social Implications (ELSI) research programmes in human genetics and nanotechnology will serve as notable examples. Indeed, future research and innovation in allergy will undoubtedly encounter ethical dilemmas and the allergology community should play a significant role in helping to address these issues. However, incorporating ethical analyses in allergology does not imply that the allergology community must acquire extensive knowledge in bioethics; instead, interdisciplinary research that incorporates expertise from allergology and bioethics would enable allergy specialists to advance critical knowledge development in this largely overlooked domain of study.
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Affiliation(s)
- Jason Behrmann
- Institute for Gender, Sexuality, and Feminist Studies, McGill University, 3487 Peel Street, 2nd floor, Montréal H3A 1W7, Canada.
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20
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Urry Z, Chambers ES, Xystrakis E, Dimeloe S, Richards DF, Gabryšová L, Christensen J, Gupta A, Saglani S, Bush A, O’Garra A, Brown Z, Hawrylowicz CM. The role of 1α,25-dihydroxyvitamin D3 and cytokines in the promotion of distinct Foxp3+ and IL-10+ CD4+ T cells. Eur J Immunol 2012; 42:2697-708. [PMID: 22903229 PMCID: PMC3471131 DOI: 10.1002/eji.201242370] [Citation(s) in RCA: 145] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 06/08/2012] [Accepted: 07/10/2012] [Indexed: 01/08/2023]
Abstract
1α,25-Dihydroxyvitamin D3 (1α25VitD3) has potent immunomodulatory properties. We have previously demonstrated that 1α25VitD3 promotes human and murine IL-10-secreting CD4(+) T cells. Because of the clinical relevance of this observation, we characterized these cells further and investigated their relationship with Foxp3(+) regulatory T (Treg) cells. 1α25VitD3 increased the frequency of both Foxp3(+) and IL-10(+) CD4(+) T cells in vitro. However, Foxp3 was increased at high concentrations of 1α25VitD3 and IL-10 at more moderate levels, with little coexpression of these molecules. The Foxp3(+) and IL-10(+) T-cell populations showed comparable suppressive activity. We demonstrate that the enhancement of Foxp3 expression by 1α25VitD3 is impaired by IL-10. 1α25VitD3 enables the selective expansion of Foxp3(+) Treg cells over their Foxp3(-) T-cell counterparts. Equally, 1α25VitD3 maintains Foxp3(+) expression by sorted populations of human and murine Treg cells upon in vitro culture. A positive in vivo correlation between vitamin D status and CD4(+) Foxp3(+) T cells in the airways was observed in a severe pediatric asthma cohort, supporting the in vitro observations. In summary, we provide evidence that 1α25VitD3 enhances the frequency of both IL-10(+) and Foxp3(+) Treg cells. In a translational setting, these data suggest that 1α25VitD3, over a broad concentration range, will be effective in enhancing the frequency of Treg cells.
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Affiliation(s)
- Zoë Urry
- MRC and Asthma-UK Centre for Allergic Mechanisms in Asthma, King’s College London, London, UK
| | - Emma S. Chambers
- MRC and Asthma-UK Centre for Allergic Mechanisms in Asthma, King’s College London, London, UK
| | - Emmanuel Xystrakis
- MRC and Asthma-UK Centre for Allergic Mechanisms in Asthma, King’s College London, London, UK
| | - Sarah Dimeloe
- MRC and Asthma-UK Centre for Allergic Mechanisms in Asthma, King’s College London, London, UK
| | - David F. Richards
- MRC and Asthma-UK Centre for Allergic Mechanisms in Asthma, King’s College London, London, UK
| | - Leona Gabryšová
- Division of Immunoregulation, MRC National Institute for Medical Research (NIMR), London, UK
| | - Jillian Christensen
- Division of Immunoregulation, MRC National Institute for Medical Research (NIMR), London, UK
| | - Atul Gupta
- MRC and Asthma-UK Centre for Allergic Mechanisms in Asthma, King’s College London, London, UK
- Imperial School of Medicine, Department of Pediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- Imperial School of Medicine, Department of Pediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Andrew Bush
- Imperial School of Medicine, Department of Pediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Anne O’Garra
- Division of Immunoregulation, MRC National Institute for Medical Research (NIMR), London, UK
| | - Zarin Brown
- Novartis Institute for Biomedical Research, Horsham, West Sussex, UK
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21
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Dimeloe S, Richards DF, Urry ZL, Gupta A, Stratigou V, Farooque S, Saglani S, Bush A, Hawrylowicz CM. 1α,25-dihydroxyvitamin D3 promotes CD200 expression by human peripheral and airway-resident T cells. Thorax 2012; 67:574-81. [PMID: 22334534 PMCID: PMC3471129 DOI: 10.1136/thoraxjnl-2011-200651] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND CD200, a cell-surface immunoglobulin-like molecule expressed by immune and stromal cells, dampens the pro-inflammatory activity of tissue-resident innate cells via its receptor, CD200R. This interaction appears critical for peripheral immune tolerance, particularly in the airways where excessive inflammation is undesirable. Vitamin D contributes to pulmonary health and promotes regulatory immune pathways, therefore its influence on CD200 and CD200R was investigated. METHODS CD200 and CD200R expression were assessed by qPCR and immunoreactivity of human lymphoid, myeloid and epithelial cells following 1α,25-dihydroxyvitamin D3 (1α,25VitD3) exposure in vitro and in peripheral T cells following 1α,25VitD3 oral ingestion in vivo. The effect of 1α25VitD3 was also assessed in human airway-resident cells. RESULTS 1α25VitD3 potently upregulated CD200 on peripheral human CD4+ T cells in vitro, and in vivo there was a trend towards upregulation in healthy, but not asthmatic individuals. CD200R expression was not modulated in any cells studied. CD200 induction was observed to a lesser extent in CD8+ T cells and not in B cells or airway epithelium. T cells isolated from the human airway also responded strongly to 1α25VitD3 to upregulate CD200. CONCLUSIONS The capacity of 1α,25-dihydroxyvitamin D3 to induce CD200 expression by peripheral and respiratory tract T cells identifies an additional pathway via which vitamin D can restrain inflammation in the airways to maintain respiratory health.
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Affiliation(s)
- Sarah Dimeloe
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, Guy’s Hospital, London, UK
| | - David F Richards
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, Guy’s Hospital, London, UK
| | - Zoe L Urry
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, Guy’s Hospital, London, UK
| | - Atul Gupta
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, Guy’s Hospital, London, UK
- Department of Pediatric Respiratory Medicine, Imperial College and Royal Brompton Hospital, London, UK
| | - Victoria Stratigou
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, Guy’s Hospital, London, UK
| | - Sophie Farooque
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, Guy’s Hospital, London, UK
| | - Sejal Saglani
- Department of Pediatric Respiratory Medicine, Imperial College and Royal Brompton Hospital, London, UK
| | - Andrew Bush
- Department of Pediatric Respiratory Medicine, Imperial College and Royal Brompton Hospital, London, UK
| | - Catherine M Hawrylowicz
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, Guy’s Hospital, London, UK
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22
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Bossley CJ, Fleming L, Gupta A, Regamey N, Frith J, Oates T, Tsartsali L, Lloyd CM, Bush A, Saglani S. Pediatric severe asthma is characterized by eosinophilia and remodeling without T(H)2 cytokines. J Allergy Clin Immunol 2012; 129:974-82.e13. [PMID: 22385633 PMCID: PMC3381727 DOI: 10.1016/j.jaci.2012.01.059] [Citation(s) in RCA: 229] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 01/17/2012] [Accepted: 01/23/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND The pathology of pediatric severe therapy-resistant asthma (STRA) is little understood. OBJECTIVES We hypothesized that STRA in children is characterized by airway eosinophilia and mast cell inflammation and is driven by the T(H)2 cytokines IL-4, IL-5, and IL-13. METHODS Sixty-nine children (mean age, 11.8 years; interquartile range, 5.6-17.3 years; patients with STRA, n = 53; control subjects, n = 16) underwent fiberoptic bronchoscopy, bronchoalveolar lavage (BAL), and endobronchial biopsy. Airway inflammation, remodeling, and BAL fluid and biopsy specimen T(H)2 cytokines were quantified. Children with STRA also underwent symptom assessment (Asthma Control Test), spirometry, exhaled nitric oxide and induced sputum evaluation. RESULTS Children with STRA had significantly increased BAL fluid and biopsy specimen eosinophil counts compared with those found in control subjects (BAL fluid, P < .001; biopsy specimen, P < .01); within the STRA group, there was marked between-patient variability in eosinophilia. Submucosal mast cell, neutrophil, and lymphocyte counts were similar in both groups. Reticular basement membrane thickness and airway smooth muscle were increased in patients with STRA compared with those found in control subjects (P < .0001 and P < .001, respectively). There was no increase in BAL fluid IL-4, IL-5, or IL-13 levels in patients with STRA compared with control subjects, and these cytokines were rarely detected in induced sputum. Biopsy IL-5(+) and IL-13(+) cell counts were also not higher in patients with STRA compared with those seen in control subjects. The subgroup (n = 15) of children with STRA with detectable BAL fluid T(H)2 cytokines had significantly lower lung function than those with undetectable BAL fluid T(H)2 cytokines. CONCLUSIONS STRA in children was characterized by remodeling and variable airway eosinophil counts. However, unlike in adults, there was no neutrophilia, and despite the wide range in eosinophil counts, the T(H)2 mediators that are thought to drive allergic asthma were mostly absent.
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Affiliation(s)
- Cara J. Bossley
- Respiratory Paediatrics, the Royal Brompton and Harefield NHS Trust, Sydney Street, London
- Leukocyte Biology Section, National Heart & Lung Institute, Imperial College London
| | - Louise Fleming
- Respiratory Paediatrics, the Royal Brompton and Harefield NHS Trust, Sydney Street, London
- Leukocyte Biology Section, National Heart & Lung Institute, Imperial College London
| | - Atul Gupta
- Respiratory Paediatrics, the Royal Brompton and Harefield NHS Trust, Sydney Street, London
- Leukocyte Biology Section, National Heart & Lung Institute, Imperial College London
| | - Nicolas Regamey
- Division of Paediatric Respiratory Medicine, Department of Paediatrics, Inselspital and University of Bern
| | - Jennifer Frith
- Respiratory Paediatrics, the Royal Brompton and Harefield NHS Trust, Sydney Street, London
| | - Timothy Oates
- Leukocyte Biology Section, National Heart & Lung Institute, Imperial College London
| | - Lemonia Tsartsali
- Respiratory Paediatrics, the Royal Brompton and Harefield NHS Trust, Sydney Street, London
| | - Clare M. Lloyd
- Leukocyte Biology Section, National Heart & Lung Institute, Imperial College London
| | - Andrew Bush
- Respiratory Paediatrics, the Royal Brompton and Harefield NHS Trust, Sydney Street, London
| | - Sejal Saglani
- Leukocyte Biology Section, National Heart & Lung Institute, Imperial College London
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Nimrey-Atrash N, Bentur L, Elias N. Subcutaneous emphysema and pneumomediastinum due to foreign body aspiration in children with asthma. Pediatr Pulmonol 2012; 47:88-90. [PMID: 21815279 DOI: 10.1002/ppul.21506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 06/19/2010] [Indexed: 11/08/2022]
Abstract
Pneumomediastinum (PM) and subcutaneous emphysema (SCE) are well recognized as complications of acute asthma exacerbation in children with asthma. We present herein a report of three cases of asthmatic children who presented with PM and SCE found to be secondary to foreign body aspiration. The cases highlight that clinicians must remain vigilant for co-morbidities in an asthma exacerbation, and less common etiologies of PM and SCE, such as foreign body aspiration, should also be carefully considered in asthmatic children.
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Gupta A, Sjoukes A, Richards D, Banya W, Hawrylowicz C, Bush A, Saglani S. Relationship between serum vitamin D, disease severity, and airway remodeling in children with asthma. Am J Respir Crit Care Med 2011; 184:1342-9. [PMID: 21908411 PMCID: PMC3471128 DOI: 10.1164/rccm.201107-1239oc] [Citation(s) in RCA: 230] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Little is known about vitamin D status and its effect on asthma pathophysiology in children with severe, therapy-resistant asthma (STRA). OBJECTIVES Relationships between serum vitamin D, lung function, and pathology were investigated in pediatric STRA. METHODS Serum 25-hydroxyvitamin D [25(OH)D(3)] was measured in 86 children (mean age, 11.7 yr): 36 with STRA, 26 with moderate asthma (MA), and 24 without asthma (control subjects). Relationships between 25(OH)D(3), the asthma control test (ACT), spirometry, corticosteroid use, and exacerbations were assessed. Twenty-two of 36 children with STRA underwent fiberoptic bronchoscopy, bronchoalveolar lavage, and endobronchial biopsy with assessment of airway inflammation and remodeling. MEASUREMENTS AND MAIN RESULTS 25(OH)D(3) levels (median [IQR]) were significantly lower in STRA (28 [22-38] nmol/L) than in MA (42.5 [29-63] nmol/L) and control subjects (56.5 [45-67] nmol/L) (P < 0.001). There was a positive relationship between 25(OH)D(3) levels and percent predicted FEV(1) (r = 0.4, P < 0.001) and FVC (r = 0.3, P = 0.002) in all subjects. 25(OH)D(3) levels were positively associated with ACT (r = 0.6, P < 0.001), and inversely associated with exacerbations (r = -0.6, P < 0.001) and inhaled steroid dose (r = -0.39, P = 0.001) in MA and STRA. Airway smooth muscle (ASM) mass, but not epithelial shedding or reticular basement membrane thickness, was inversely related to 25(OH)D(3) levels (r = -0.6, P = 0.008). There was a positive correlation between ASM mass and bronchodilator reversibility (r = 0.6, P = 0.009) and an inverse correlation between ASM mass and ACT (r = -0.7, P < 0.001). CONCLUSIONS Lower vitamin D levels in children with STRA were associated with increased ASM mass and worse asthma control and lung function. The link between vitamin D, airway structure, and function suggests vitamin D supplementation may be useful in pediatric STRA.
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Affiliation(s)
- Atul Gupta
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK.
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25
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[Pediatric bronchoscopy guidelines]. Arch Bronconeumol 2011; 47:350-60. [PMID: 21600686 DOI: 10.1016/j.arbres.2011.04.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 03/28/2011] [Accepted: 04/02/2011] [Indexed: 11/24/2022]
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Fitzpatrick AM, Stephenson ST, Hadley GR, Burwell L, Penugonda M, Simon DM, Hansen J, Jones DP, Brown LAS. Thiol redox disturbances in children with severe asthma are associated with posttranslational modification of the transcription factor nuclear factor (erythroid-derived 2)-like 2. J Allergy Clin Immunol 2011; 127:1604-11. [PMID: 21514635 DOI: 10.1016/j.jaci.2011.03.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 03/27/2011] [Accepted: 03/28/2011] [Indexed: 12/30/2022]
Abstract
BACKGROUND Airway thiol redox disturbances, including depletion of the antioxidant, glutathione, are differentiating features of severe asthma in children. OBJECTIVES Given the role of the transcription factor nuclear factor (erythroid-derived 2)-like 2 (Nrf2) in maintaining glutathione homeostasis and antioxidant defense, we quantified expression and activity of Nrf2 and its downstream targets in the airways and systemic circulation of children with asthma. We hypothesized that Nrf2 activation and function would be impaired in severe asthma, resulting in depletion of thiol pools and insufficient glutathione synthesis and conjugation. METHODS PBMCs and airway lavage cells were collected from children 6 to 17 years with severe (n = 51) and mild-to-moderate asthma (n = 38). The thiols glutathione and cysteine were quantified, and expression and activity of Nrf2 and its downstream targets were assessed. RESULTS Children with severe asthma had greater oxidation and lower concentrations of glutathione and cysteine in the plasma and airway lavage. Although Nrf2 mRNA and protein increased in severe asthma as a function of increased thiol oxidation, the Nrf2 expressed was highly dysfunctional. Nrf2 activation and downstream targets of Nrf2 binding, including glutathione-dependent enzymes, were not different between groups. The duration of asthma was a key factor associated with Nrf2 dysfunction in severe asthma. CONCLUSION Children with severe asthma have a global disruption of thiol redox signaling and control in both the airways and systemic circulation that is associated with posttranslational modification of Nrf2. We conclude that the Nrf2 pathway is disrupted in severe asthma as a function of chronic oxidative stress, which ultimately inhibits glutathione synthesis and antioxidant defense.
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The molecular phenotype of severe asthma in children. J Allergy Clin Immunol 2010; 125:851-857.e18. [PMID: 20371397 DOI: 10.1016/j.jaci.2010.01.048] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Revised: 01/06/2010] [Accepted: 01/28/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although the clinical attributes of severe asthma in children have been well described, the differentiating features of the lower airway inflammatory response are less understood. OBJECTIVES We sought to discriminate severe from moderate asthma in children by applying linear discriminant analysis, a supervised method of high-dimensional data reduction, to cytokines and chemokines measured in the bronchoalveolar lavage (BAL) fluid and alveolar macrophage (AM) lysate. METHODS Bronchoalveolar lavage fluid was available from 53 children with asthma (severe asthma, n = 31) undergoing bronchoscopy for clinical indications and 30 nonsmoking adults. Twenty-three cytokines and chemokines were measured by using bead-based multiplex assays. Linear discriminant analyses of the BAL fluid and AM analytes were performed to develop predictive models of severe asthma in children. RESULTS Although univariate analysis of single analytes did not differentiate severe from moderate asthma in children, linear discriminant analyses allowed for near complete separation of the moderate and severe asthmatic groups. Significant correlations were also noted between several of the AM and BAL analytes measured. In the BAL fluid, IL-13 and IL-6 differentiated subjects with asthma from controls, whereas growth-related oncogene (CXCL1), RANTES (CCL5), IL-12, IFN-gamma, and IL-10 best characterized severe versus moderate asthma in children. In the AM lysate, IL-6 was the strongest discriminator of all the groups. CONCLUSION Severe asthma in children is characterized by a distinct airway molecular phenotype that does not have a clear T(H)1 or T(H)2 pattern. Improved classification of children with severe asthma may assist with the development of targeted therapeutics for this group of children who are difficult to treat.
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Griesenbach U, Soussi S, Larsen MB, Casamayor I, Dewar A, Regamey N, Bush A, Shah PL, Davies JC, Alton EWFW. Quantification of periciliary fluid height in human airway biopsies is feasible, but not suitable as a biomarker. Am J Respir Cell Mol Biol 2010; 44:309-15. [PMID: 20418361 DOI: 10.1165/rcmb.2009-0265oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The "low volume hypothesis," stating that imbalanced ion movement across the cystic fibrosis (CF) airway epithelium leads to a reduction in periciliary fluid (PCL) and consequently impaired mucociliary clearance, has been the prevailing theory explaining CF pathophysiology, and has been supported by animal models and ex vivo cell culture systems. However, studies in freshly obtained human tissue have not yet been performed. Methods to quantify PCL height in freshly obtained airway biopsies may be useful to assess efficacy of new treatments aimed at restoring PCL height. Here, we established methods to quantify PCL height in freshly obtained CF and non-CF human lower airway biopsies. More than 90% of biopsies contained ciliated epithelium, and PCL height measurements were feasible in approximately 50% of these. Although the mean PCL height was reduced in CF tissue (non-CF, 5.60 ± 0.28 μm; CF, 4.52 ± 0.47 μm), this did not reach statistical significance (P = 0.06). To strengthen the data, we performed similar studies in wild-type and CF knockout mice, and confirmed the results (non-CF, 4.70 ± 0.13; CF, 4.10 ± 0.09 μm; P < 0.05). PCL height measurements in freshly obtained human airway biopsies are feasible, and PCL height appears reduced in subjects with CF, thereby further supporting the "low volume hypothesis." However, power calculations indicate that this assay can only be considered as a biomarker in large, late-phase clinical trials, because sample sizes required to achieve sufficient power are comparatively large.
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Hilty M, Burke C, Pedro H, Cardenas P, Bush A, Bossley C, Davies J, Ervine A, Poulter L, Pachter L, Moffatt MF, Cookson WOC. Disordered microbial communities in asthmatic airways. PLoS One 2010; 5:e8578. [PMID: 20052417 PMCID: PMC2798952 DOI: 10.1371/journal.pone.0008578] [Citation(s) in RCA: 1220] [Impact Index Per Article: 87.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Accepted: 12/12/2009] [Indexed: 12/16/2022] Open
Abstract
Background A rich microbial environment in infancy protects against asthma [1], [2] and infections precipitate asthma exacerbations [3]. We compared the airway microbiota at three levels in adult patients with asthma, the related condition of COPD, and controls. We also studied bronchial lavage from asthmatic children and controls. Principal Findings We identified 5,054 16S rRNA bacterial sequences from 43 subjects, detecting >70% of species present. The bronchial tree was not sterile, and contained a mean of 2,000 bacterial genomes per cm2 surface sampled. Pathogenic Proteobacteria, particularly Haemophilus spp., were much more frequent in bronchi of adult asthmatics or patients with COPD than controls. We found similar highly significant increases in Proteobacteria in asthmatic children. Conversely, Bacteroidetes, particularly Prevotella spp., were more frequent in controls than adult or child asthmatics or COPD patients. Significance The results show the bronchial tree to contain a characteristic microbiota, and suggest that this microbiota is disturbed in asthmatic airways.
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Affiliation(s)
- Markus Hilty
- National Heart and Lung Institute, Imperial College London, London, England
| | - Conor Burke
- Department of Respiratory Medicine, Connolly Hospital, Dublin, Ireland
| | - Helder Pedro
- Instituto Gulbenkian de Ciência, Instituto de Tecnologia Química e Biológica, Oeiras, Portugal
- Department of Mathematics, University of California, Berkeley, California, United States of America
| | - Paul Cardenas
- National Heart and Lung Institute, Imperial College London, London, England
| | - Andy Bush
- National Heart and Lung Institute, Imperial College London, London, England
| | - Cara Bossley
- National Heart and Lung Institute, Imperial College London, London, England
| | - Jane Davies
- National Heart and Lung Institute, Imperial College London, London, England
| | - Aaron Ervine
- Department of Respiratory Medicine, Connolly Hospital, Dublin, Ireland
| | - Len Poulter
- Department of Respiratory Medicine, Connolly Hospital, Dublin, Ireland
| | - Lior Pachter
- Department of Mathematics, University of California, Berkeley, California, United States of America
| | - Miriam F. Moffatt
- National Heart and Lung Institute, Imperial College London, London, England
| | - William O. C. Cookson
- National Heart and Lung Institute, Imperial College London, London, England
- * E-mail:
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Levels of nitric oxide oxidation products are increased in the epithelial lining fluid of children with persistent asthma. J Allergy Clin Immunol 2009; 124:990-6.e1-9. [PMID: 19895987 DOI: 10.1016/j.jaci.2009.08.039] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Revised: 08/05/2009] [Accepted: 08/25/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Children with severe allergic asthma have persistent airway inflammation and oxidant stress. OBJECTIVES We hypothesized that children with severe allergic asthma would have increased concentrations of the nitric oxide (NO) oxidation products nitrite, nitrate, and nitrotyrosine in the proximal and distal airway epithelial lining fluid (ELF). We further hypothesized that NO oxidation products would be associated with higher exhaled NO values (fraction of exhaled nitric oxide [F(ENO)]), greater allergic sensitization, and lower pulmonary function. METHODS Bronchoalveolar lavage fluid was obtained from 15 children with mild-to-moderate asthma, 30 children with severe allergic asthma, 5 nonasthmatic children, and 20 nonsmoking adults. The bronchoalveolar lavage fluid was divided into proximal and distal portions and nitrite, nitrate, and nitrotyrosine values were quantified. RESULTS Children with mild-to-moderate and severe allergic asthma had increased concentrations of nitrite (adult control subjects, 15 +/- 3 micromol/L; pediatric control subjects, 23 +/- 4 micromol/L; subjects with mild-to-moderate asthma, 56 +/- 26 micromol/L; subjects with severe asthma, 74 +/- 18 micromol/L), nitrate (37 +/- 13 vs 145 +/- 38 vs 711 +/- 155 vs 870 +/- 168 micromol/L, respectively) and nitrotyrosine (2 +/- 1 vs 3 +/- 1 vs 9 +/- 3 vs 10 +/- 4 micromol/L, respectively) in the proximal ELF. Similar results were seen in the distal ELF, although the concentrations were significantly lower (P < .05 for each). Although univariate analyses revealed no associations between NO oxidation products and clinical features, multivariate analyses revealed F(ENO) values to be a significant predictor of NO oxidation in asthmatic children. CONCLUSIONS NO oxidation products are increased in the ELF of asthmatic children. The relationship between F(ENO) values and airway nitrosative stress is complicated and requires further study.
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Bossley C, Saglani S, Kavanagh C, Payne D, Wilson N, Tsartsali L, Rosenthal M, Balfour-Lynn I, Nicholson A, Bush A. Corticosteroid responsiveness and clinical characteristics in childhood difficult asthma. Eur Respir J 2009; 34:1052-9. [PMID: 19541710 PMCID: PMC3471127 DOI: 10.1183/09031936.00186508] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This study describes the clinical characteristics and corticosteroid responsiveness of children with difficult asthma (DA). We hypothesised that complete corticosteroid responsiveness (defined as improved symptoms, normal spirometry, normal exhaled nitric oxide fraction (F(eNO)) and no bronchodilator responsiveness (BDR <12%)) is uncommon in paediatric DA. We report on 102 children, mean+/-sd age 11.6+/-2.8 yrs, with DA in a cross-sectional study. 89 children underwent spirometry, BDR and F(eNO) before and after 2 weeks of systemic corticosteroids (corticosteroid response study). Bronchoscopy was performed after the corticosteroid trial. Of the 102 patients in the cross-sectional study, 88 (86%) were atopic, 60 (59%) were male and 52 (51%) had additional or alternative diagnoses. Out of the 81 patients in the corticosteroid response study, nine (11%) were complete responders. Of the 75 patients with symptom data available, 37 (49%) responded symptomatically, which was less likely if there were smokers in the home (OR 0.31, 95% CI 0.02-0.82). Of the 75 patients with available spirometry data, 35 (46%) had normal spirometry, with associations being BAL eosinophilia (OR 5.43, 95% CI 1.13-26.07) and high baseline forced expiratory volume in 1 s (FEV(1)) (OR 1.08, 95% CI 1.02-1.12). Of these 75 patients, BDR data were available in 64, of whom 36 (56%) had <12% BDR. F(eNO) data was available in 70 patients, of whom 53 (75%) had normal F(eNO). Airflow limitation data was available in 75 patients, of whom 17 (26%) had persistent airflow limitation, which was associated with low baseline FEV(1) (OR 0.93, 95% CI 0.90-0.97). Only 11% of DA children exhibited complete corticosteroid responsiveness. The rarity of complete corticosteroid responsiveness suggests alternative therapies are needed for children with DA.
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Affiliation(s)
- C.J. Bossley
- Dept of Respiratory Paediatrics, Royal Brompton Hospital
| | | | - C. Kavanagh
- Dept of Respiratory Paediatrics, Royal Brompton Hospital
| | - D.N.R. Payne
- Dept of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - N. Wilson
- Dept of Respiratory Paediatrics, Royal Brompton Hospital
| | - L. Tsartsali
- Dept of Respiratory Paediatrics, Royal Brompton Hospital
| | - M. Rosenthal
- Dept of Respiratory Paediatrics, Royal Brompton Hospital
| | | | | | - A. Bush
- Dept of Respiratory Paediatrics, Royal Brompton Hospital
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Fitzpatrick AM, Teague WG, Holguin F, Yeh M, Brown LAS. Airway glutathione homeostasis is altered in children with severe asthma: evidence for oxidant stress. J Allergy Clin Immunol 2009; 123:146-152.e8. [PMID: 19130935 DOI: 10.1016/j.jaci.2008.10.047] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Revised: 10/24/2008] [Accepted: 10/28/2008] [Indexed: 01/06/2023]
Abstract
BACKGROUND Severe asthma is characterized by persistent airway inflammation and increased formation of reactive oxygen species. OBJECTIVES Glutathione (GSH) is an important antioxidant in the epithelial lining fluid (ELF). We hypothesized that airway GSH homeostasis was altered in children with severe asthma and was characterized by decreased GSH and increased glutathione disulfide (GSSG) concentrations. METHODS Bronchoalveolar lavage was obtained from 65 children with severe asthma, including 35 children with baseline airway obstruction evidenced by FEV(1) <80%. Control data were obtained from 6 children with psychogenic (habit) cough or vocal cord dysfunction undergoing diagnostic bronchoscopy and 35 healthy adult controls. GSH, GSSG, and other determinants of airway oxidative stress including glutathione S-transferase (GST), glutathione reductase (GR), glutathione peroxidase (GPx), malondialdehyde, 8-isoprostane, and H(2)O(2) were measured in the ELF. The ELF redox potential was calculated from GSH and GSSG by using the Nernst equation. RESULTS Compared with controls, subjects with severe asthma had lower airway GSH with increased GSSG despite no differences in GST, GR, and GPx activities between groups. This was accompanied by increased malondialdehyde, 8-isoprostane, and H(2)O(2) concentrations in the ELF. GSH oxidation was most apparent in subjects with severe asthma with airway obstruction and was supported by an upward shift in the ELF GSH redox potential. CONCLUSION Children with severe asthma have increased biomarkers of oxidant stress in the ELF that are associated with increased formation of GSSG and a shift in the GSH redox potential toward the more oxidized state.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.
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Regamey N, Balfour-Lynn I, Rosenthal M, Hogg C, Bush A, Davies JC. Time required to obtain endobronchial biopsies in children during fiberoptic bronchoscopy. Pediatr Pulmonol 2009; 44:76-9. [PMID: 19085925 DOI: 10.1002/ppul.20949] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Endobronchial biopsies are an important tool for the study of airway remodeling in children. We aimed to evaluate the impact of performing endobronchial biopsies as a part of fiberoptic bronchoscopy on the length of the procedure. METHODS Clinically indicated fiberoptic bronchoscopy at which endobronchial biopsy was attempted as a part of a research protocol was performed in 40 children (median age 6 years, range 2 months-16 years). Time needed for airway inspection, bronchoalveolar lavage (BAL) with three aliquots of 1 ml/kg of 0.9% saline, sampling of three macroscopically adequate biopsies, teaching, and other interventions (e.g., removal of plugs) was recorded. The bronchoscopist was not aware that the procedure was being timed. RESULTS Median (range) duration (min) was 2.5 (1.0-8.2) for airway inspection, 2.8 (1.7-9.4) for BAL, 5.3 (2.5-16.6) for biopsy sampling, 2.4 (1.5-6.6) for teaching and 4.1 (0.8-18.5) for other interventions. Three adequate biopsies were obtained in 33 (83%) children. Use of 2.0 mm biopsy forceps (via 4.0 and 4.9 mm bronchoscopes) rather than 1.0 mm (via 2.8 and 3.6 mm bronchoscopes) significantly reduced biopsy time (4.6 min vs. 8.4 min, P < 0.001). CONCLUSIONS It takes a median of just over 5 min to obtain three endobronchial biopsies in children, which we consider an acceptable increase in the duration of fiberoptic bronchoscopy for the purpose of research.
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Affiliation(s)
- Nicolas Regamey
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom.
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Erlewyn-Lajeunesse MDS, Hunt LP, Pohunek P, Dobson SJ, Kochhar P, Warner JA, Warner JO. Bronchoalveolar lavage MMP-9 and TIMP-1 in preschool wheezers and their relationship to persistent wheeze. Pediatr Res 2008; 64:194-9. [PMID: 18391843 DOI: 10.1203/pdr.0b013e318175dd2d] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Atopic preschool children are more likely to develop persistent wheezing, which could be a consequence of early airway remodeling. Protease-antiprotease balance between MMP-9 and its cognate inhibitor TIMP-1 may be involved in this process. Our hypothesis was that atopic wheezing preschool children would have an imbalance of MMP-9 to TIMP-1 in bronchoalveolar lavage (BAL). BAL from 52 preschool wheezers was compared with 14 controls without wheeze. A subgroup completed an International Study of Asthma and Allergy in Childhood symptom questionnaire 2 y later. Molar ratios of MMP-9/TIMP-1 were higher in wheezy children (p < 0.001; median 4.0%, range 0-8.7) than controls (0.6%, 0-1.8), and showed an excess of TIMP-1 in the airway. BAL TIMP-1 was raised in children with persistent wheezing (p = 0.028; 34.4 ng/mL, 9.1-93.1 compared with 10.6 ng/mL 6.1-18.6), as was serum levels of intercellular adhesion molecule-1 (p = 0.027). The absolute concentration of TIMP-1 in the airway, rather than its molar ratio with MMP-9, was associated with persistent wheezing. The processes involved with airway remodeling are complex but excess TIMP-1 may impede matrix protein turnover and thereby contribute to persistent changes in airway structure and wheezing.
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Fayon M, Chiron R, Abely M. Mesure de l’inflammation pulmonaire dans la mucoviscidose. Rev Mal Respir 2008; 25:705-24. [DOI: 10.1016/s0761-8425(08)73800-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fonseca MTM, Camargos PAM, Abou Taam R, Le Bourgeois M, Scheinmann P, de Blic J. Incidence rate and factors related to post-bronchoalveolar lavage fever in children. Respiration 2007; 74:653-8. [PMID: 17728531 DOI: 10.1159/000107737] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2006] [Accepted: 06/05/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Post-bronchoscopy and bronchoalveolar lavage (BAL) fever in children has been described by several authors. OBJECTIVES This study aimed at assessing the occurrence of fever after these examinations and associated risk factors. METHODS The study was performed in the Bronchoscopy Unit of Hôpital Necker-Enfants Malades, Paris, France, from June 2004 to July 2005. 148 children who underwent fiberoptic bronchoscopy and BAL, and remained in the Unit for 24 h, were included. RESULTS 37.8% of the patients presented post-BAL fever. In the multivariate analysis of the selected factors (age, immunodeficiency, general or local anesthesia, mucosal biopsy, inflammation and suppuration at the moment of the examination, abnormal bronchoalveolar fluid cellularity and infection), only age <2 years and presence of infection remained associated with fever. CONCLUSIONS The occurrence of fever is a frequent event in children who underwent BAL. In order to reduce post-BAL fever, antibiotic strategies should be devised based on prospective studies assessing identification of predictive air-way infection criteria and/or rapid bacteriological result analysis.
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Affiliation(s)
- M T Mohallem Fonseca
- Departamento de Pediatria da Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Regamey N, Hilliard TN, Saglani S, Zhu J, Scallan M, Balfour-Lynn IM, Rosenthal M, Jeffery PK, Alton EWFW, Bush A, Davies JC. Quality, size, and composition of pediatric endobronchial biopsies in cystic fibrosis. Chest 2007; 131:1710-7. [PMID: 17317731 DOI: 10.1378/chest.06-2666] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Studies on airway remodeling in children with cystic fibrosis (CF) may be hampered by difficulty in obtaining evaluable endobronchial biopsy specimens because of large amounts of mucus and inflammation in the CF airway. We prospectively assessed how the quality of biopsy specimens obtained from children with CF compare with those from children with other airway diseases. METHODS Fiberoptic bronchoscopy with endobronchial biopsy was performed in 67 CF children (age range, 0.2 to 16.8 years), 34 children with wheeze/asthma (W/A), and 64 control children with chronic respiratory symptoms. Up to three biopsy specimens were taken and stained with hematoxylin and eosin. Biopsy specimen size and structural composition were quantified using stereology. RESULTS At least one evaluable biopsy specimen was obtained in 72% of CF children, in 79% of children with W/A, and in 72% of control subjects (difference was not significant). The use of large biopsy forceps (2.0 mm) rather than small biopsy forceps (1.0 mm) [odds ratio (OR), 5.8; 95% confidence interval (CI), 1.1 to 29.8; p = 0.037] and the number of biopsy specimens taken (odds ratio, 2.6; 95% confidence interval, 1.3 to 5.2; p = 0.006) significantly contributed to the success rate. Biopsy size and composition were similar between groups, except that CF children and those patients with W/A had a higher percentage of the biopsy specimen composed of muscle than did control subjects (median 6.2% and 9.7% vs 0.9%, respectively; p = 0.002). CONCLUSIONS Biopsy size and quality are adequate for the study of airway remodeling in CF children as young as 2 months of age. Researchers should use large forceps when possible and take at least two biopsy specimens per patient. An increased airway smooth muscle content of the airway mucosa may contribute to the pathophysiology of CF lung disease.
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Affiliation(s)
- Nicolas Regamey
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK.
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Molina-Teran A, Hilliard TN, Saglani S, Haxby E, Scallan M, Bush A, Davies JC. Safety of endobronchial biopsy in children with cystic fibrosis. Pediatr Pulmonol 2006; 41:1021-4. [PMID: 16998852 DOI: 10.1002/ppul.20365] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
There is little found in the published literature regarding the use of endobronchial biopsy (EBB) in children with cystic fibrosis (CF). One concern over the use of the technique may relate to safety, in particular increased risk of bleeding from a hypertrophied bronchial circulation. The aim of this retrospective study was to compare the safety of EBB in children with CF and those with other conditions, the most frequent of which included primary ciliary dyskinesia and recurrent lower respiratory tract infections. Case notes of all children undergoing EBB in our institution between February 2003 and May 2004 were reviewed. EBB was performed during 45 bronchoscopies in 42 CF patients (19 males, group mean age 7.13 +/- 4.48 years) and in 39 controls (20 males, group mean age 6.59 +/- 4.48 years). There were no significant differences between disease groups in the number, type, or severity of complications occurring during or in the first 12 hr after the procedure. We conclude that EBB performed as part of fibreoptic bronchoscopy (FOB) under general anaesthesia can be performed safely in children with CF, when both bronchoscopist and anaesthetist are suitably experienced. Studies of such samples would allow us to determine the early pathological changes in the CF airway and possibly find new treatments to prevent the progression to bronchiectasis and end stage airway destruction.
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Affiliation(s)
- A Molina-Teran
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
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Abstract
Research has brought significant medical advances in modern times benefiting virtually all people. Children as a class should not be excluded from research studies. However, non-therapeutic research is potentially problematic in children because they must be afforded special protection from harm and exploitation by care-givers, researchers, and institutional review boards. An article in this month's journal provides an opportunity for a systematic analysis using the methodology provided by the United States Code of Federal Regulations. The research design of this particular study does not appear to stand up to the requirements of the Code.
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Affiliation(s)
- George B Mallory
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas 77030, USA.
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Lex C, Ferreira F, Zacharasiewicz A, Nicholson AG, Haslam PL, Wilson NM, Hansel TT, Payne DNR, Bush A. Airway eosinophilia in children with severe asthma: predictive values of noninvasive tests. Am J Respir Crit Care Med 2006; 174:1286-91. [PMID: 16973985 DOI: 10.1164/rccm.200603-352oc] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Children with severe asthma experience persistent symptoms despite maximal conventional treatment. Fraction of exhaled nitric oxide (Fe(NO)) and sputum eosinophils are used as markers of airway inflammation to guide treatment with steroids, but no data are available on how reliable they are in predicting airway eosinophilia assessed bronchoscopically in these children. OBJECTIVES To determine how Fe(NO) and sputum eosinophils predict airway eosinophilia measured in both bronchoalveolar lavage (BAL) and endobronchial biopsy. METHODS Twenty-seven children with moderate to severe persistent asthma attempted measurement of Fe(NO) and sputum eosinophils, followed by bronchoscopy, BAL, and endobronchial biopsy within 24 h. MAIN RESULTS Significant correlations were found between eosinophils in sputum and both BAL eosinophils (n = 20, r = 0.45, p = 0.045) and Fe(NO) (n = 23, r = 0.42, p = 0.049). The relationship between Fe(NO) and BAL eosinophils was also significant with a stronger correlation (n = 24, r = 0.54, p = 0.006). The positive predictive value (PPV) for increased sputum eosinophil percentage (> 2.5%) to detect elevated eosinophils in BAL (> 1.19%) was 75%; the negative predictive value (NPV) was 63%. All patients with both increased sputum eosinophils and an elevated Fe(NO) value (> 23 ppb) had elevated eosinophils in BAL (PPV, 100%); the NPV of these two markers was 65%. Eight of nine patients without any sputum eosinophils had normal subepithelial eosinophil numbers (< 1.2%; NPV, 89%). However, the PPV of any sputum eosinophils for increased subepithelial eosinophilia was only 36.4%. CONCLUSIONS There was moderate agreement between both Fe(NO) and sputum eosinophils and BAL eosinophils. There was good NPV, but only poor PPV for these markers for mucosal eosinophilia.
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Affiliation(s)
- Christiane Lex
- Department of Pediatric Respiratory Medicine, Imperial College of Science, Technology, and Medicine at the Royal Brompton Hospital and National Heart and Lung Institute, Sydney Street, London SW3 6NP, UK
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Abstract
Asthma is a chronic inflammatory disease involving many different cell types and cellular elements. Evidence suggests that, in the long term, this inflammation leads to remodeling of the airways, airflow obstruction, and the bronchial hyperreactivity symptoms of asthma, and is present even in patients with intermittent disease. Patients with allergic asthma and those with seasonal allergic rhinitis are believed to have minimal persistent inflammation, and the two diseases often occur together. Early intervention with inhaled corticosteroids (ICS) is believed to modify the disease process and may limit long-term remodeling. ICS remain the cornerstone and "gold standard" of treatment for asthma.
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Affiliation(s)
- G Walter Canonica
- Allergy and Respiratory Diseases, DIMI, Department of Internal Medicine, University of Genoa, Genoa, Italy.
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45
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Affiliation(s)
- Andrew Bush
- Imperial School of Medicine, National Heart and Lung Institute, London, United Kingdom.
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46
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Lex C, Zacharasiewicz A, Payne DNR, Wilson NM, Nicholson AG, Kharitonov SA, Barnes PJ, Bush A. Exhaled breath condensate cysteinyl leukotrienes and airway remodeling in childhood asthma: a pilot study. Respir Res 2006; 7:63. [PMID: 16603074 PMCID: PMC1456970 DOI: 10.1186/1465-9921-7-63] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2005] [Accepted: 04/07/2006] [Indexed: 11/10/2022] Open
Abstract
Background It has been suggested that cysteinyl leukotrienes (cysLTs) play an important role in airway remodeling. Previous reports have indicated that cysLTs augment human airway smooth muscle cell proliferation. Recently, cysLTs have been measured in exhaled breath condensate (EBC). The aim of this study was to evaluate the relationship between cysLTs in EBC and another marker of airway remodeling, reticular basement membrane (RBM) thickening, in endobronchial biopsies in children. Methods 29 children, aged 4–15 years, with moderate to severe persistent asthma, who underwent bronchoscopy as part of their clinical assessment, were included. Subjects underwent spirometry and EBC collection for cysLTs analysis, followed by bronchoscopy and endobronchial biopsy within 24 hours. Results EBC cysLTs were significantly lower in asthmatic children who were treated with montelukast than in those who were not (median (interquartile range) 36.62 (22.60–101.05) versus 249.1 (74.21–526.36) pg/ml, p = 0.004). There was a significant relationship between EBC cysLTs and RBM thickness in the subgroup of children who were not treated with montelukast (n = 13, r = 0.75, p = 0.003). Conclusion EBC cysLTs appear to be associated with RBM thickening in asthma.
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Affiliation(s)
- Christiane Lex
- Department of Paediatric Respiratory Medicine, Imperial College of Science, Technology and Medicine at the Royal Brompton Hospital and National Heart and Lung Institute, London, UK
- Department of Paediatric Cardiology and Pulmonology, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Angela Zacharasiewicz
- Department of Paediatric Respiratory Medicine, Imperial College of Science, Technology and Medicine at the Royal Brompton Hospital and National Heart and Lung Institute, London, UK
- Department of Paediatric and Adolescent Medicine, Pulmonary and Infectious Diseases, Wilhelminenspital Vienna, Austria
| | - Donald NR Payne
- Department of Paediatric Respiratory Medicine, Imperial College of Science, Technology and Medicine at the Royal Brompton Hospital and National Heart and Lung Institute, London, UK
| | - Nicola M Wilson
- Department of Paediatric Respiratory Medicine, Imperial College of Science, Technology and Medicine at the Royal Brompton Hospital and National Heart and Lung Institute, London, UK
| | - Andrew G Nicholson
- Department of Histopathology, Imperial College of Science, Technology and Medicine at the Royal Brompton Hospital and National Heart and Lung Institute, London, UK
| | - Sergei A Kharitonov
- Department of Thoracic Medicine, Imperial College of Science, Technology and Medicine at the Royal Brompton Hospital and National Heart and Lung Institute, London, UK
| | - Peter J Barnes
- Department of Thoracic Medicine, Imperial College of Science, Technology and Medicine at the Royal Brompton Hospital and National Heart and Lung Institute, London, UK
| | - Andrew Bush
- Department of Paediatric Respiratory Medicine, Imperial College of Science, Technology and Medicine at the Royal Brompton Hospital and National Heart and Lung Institute, London, UK
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Saglani S, Papaioannou G, Khoo L, Ujita M, Jeffery PK, Owens C, Hansell DM, Payne DN, Bush A. Can HRCT be used as a marker of airway remodelling in children with difficult asthma? Respir Res 2006; 7:46. [PMID: 16566832 PMCID: PMC1435892 DOI: 10.1186/1465-9921-7-46] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2005] [Accepted: 03/27/2006] [Indexed: 11/17/2022] Open
Abstract
Background Whole airway wall thickening on high resolution computed tomography (HRCT) is reported to parallel thickening of the bronchial epithelial reticular basement membrane (RBM) in adult asthmatics. A similar relationship in children with difficult asthma (DA), in whom RBM thickening is a known feature, may allow the use of HRCT as a non-invasive marker of airway remodelling. We evaluated this relationship in children with DA. Methods 27 children (median age 10.5 [range 4.1–16.7] years) with DA, underwent endobronchial biopsy from the right lower lobe and HRCT less than 4 months apart. HRCTs were assessed for bronchial wall thickening (BWT) of the right lower lobe using semi-quantitative and quantitative scoring techniques. The semi-quantitative score (grade 0–4) was an overall assessment of BWT of all clearly identifiable airways in HRCT scans. The quantitative score (BWT %; defined as [airway outer diameter – airway lumen diameter]/airway outer diameter ×100) was the average score of all airways visible and calculated using electronic endpoint callipers. RBM thickness in endobronchial biopsies was measured using image analysis. 23/27 subjects performed spirometry and the relationships between RBM thickness and BWT with airflow obstruction evaluated. Results Median RBM thickness in endobronchial biopsies was 6.7(range 4.6 – 10.0) μm. Median qualitative score for BWT of the right lower lobe was 1(range 0 – 1.5) and quantitative score was 54.3 (range 48.2 – 65.6)%. There was no relationship between RBM thickness and BWT in the right lower lobe using either scoring technique. No relationship was found between FEV1 and BWT or RBM thickness. Conclusion Although a relationship between RBM thickness and BWT on HRCT has been found in adults with asthma, this relationship does not appear to hold true in children with DA.
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Affiliation(s)
- S Saglani
- Respiratory Paediatrics, Royal Brompton Hospital, London, UK
- Lung Pathology, Imperial College London at the Royal Brompton Hospital, London, UK
| | - G Papaioannou
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - L Khoo
- Department of Radiology, Royal Brompton Hospital, London, UK
| | - M Ujita
- Department of Radiology, Royal Brompton Hospital, London, UK
| | - PK Jeffery
- Lung Pathology, Imperial College London at the Royal Brompton Hospital, London, UK
| | - C Owens
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - DM Hansell
- Department of Radiology, Royal Brompton Hospital, London, UK
| | - DN Payne
- Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - A Bush
- Respiratory Paediatrics, Royal Brompton Hospital, London, UK
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48
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López-Viña A, Agüero-Balbín R, Aller-Alvarez JL, Bazús-González T, Cosio BG, García-Cosio FB, de Diego-Damiá A, Martínez-Moragón E, Pereira-Vega A, Plaza-Moral V, Rodríguez-Trigo G, Villa-Asensi JR. [Guidelines for the diagnosis and management of difficult-to-control asthma]. Arch Bronconeumol 2005; 41:513-23. [PMID: 16194515 DOI: 10.1016/s1579-2129(06)60272-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- A López-Viña
- Servicio de Neumología, Hospital Universitario Puerta de Hierro, Madrid, Spain.
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49
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Housset B. Actualités diagnostiques. Rev Mal Respir 2005. [DOI: 10.1016/s0761-8425(05)85657-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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50
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Wahidi MM, Rocha AT, Hollingsworth JW, Govert JA, Feller-Kopman D, Ernst A. Contraindications and safety of transbronchial lung biopsy via flexible bronchoscopy. A survey of pulmonologists and review of the literature. Respiration 2005; 72:285-95. [PMID: 15942298 DOI: 10.1159/000085370] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2003] [Accepted: 10/06/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Transbronchial lung biopsy (TBLB) via flexible bronchoscopy is a common procedure performed by pulmonologists. Limited scientific data exist concerning the risk of this procedure in patients with conditions that may adversely affect the rate of procedural complications. OBJECTIVES To evaluate the current practice pattern and attitude of pulmonologists toward the performance of TBLB in the presence of high-risk conditions. METHODS A survey was constructed and distributed at the American College of Chest Physicians annual meeting, held in Philadelphia, USA, in November of 2001. RESULTS A total of 227 surveys were distributed with a return of 158 (69.6%). Anticoagulation medications are temporarily held prior to TBLB by the majority of our survey respondents (98.7% for intravenous heparin, 90.5% for warfarin, and 87.3% for low-molecular-weight heparin). Medications with effect on platelet function are held by fewer pulmonologists. There is a wide variation in the pulmonologists' perception of the risk of performing TBLB when certain medical conditions coexist: pulmonary hypertension [absolute contraindication (AC), 28.7%; relative contraindication (RC) 58.6%], superior vena cava syndrome (AC 19.6%, RC 51%), mechanical ventilation (AC 17.8%, RC 58.6%) and lung cavity/abscess (AC 7%, RC 44.9%). A significant percentage of pulmonologists (55%) do not regard an elevated serum creatinine at any level as AC to TBLB. Thirty-eight percent of the survey participants administer desmopressin prior to TBLB in uremic patients to prevent excessive bleeding. CONCLUSIONS Prior to performing bronchoscopic TBLB, the majority of pulmonologists temporarily holds anticoagulation medications. However, there is a lack of agreement in relation to perceived contraindications and safety of TBLB.
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Affiliation(s)
- Momen M Wahidi
- Departments of Internal Medicine, Division of Pulmonary Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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