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Wong MD, Condon K, Robinson PD, Suresh S, Zahir SF, Sly PD, Blake TL. Assessment of bronchodilator response in preschoolers: A systematic review. Pediatr Pulmonol 2024. [PMID: 38953717 DOI: 10.1002/ppul.27112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 04/25/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Several techniques can be used to assess bronchodilator response (BDR) in preschool-aged children, including spirometry, respiratory oscillometry, the interrupter technique, and specific airway resistance. However, there has not been a systematic comparison of BDR thresholds across studies yet. METHODS A systematic review was performed on all studies up to May 2023 measuring a bronchodilator effect in children 2-6 years old using one of these techniques (PROSPERO CRD42021264659). Studies were identified using MEDLINE, Cochrane, EMBASE, CINAHL via EBSCO, Web of Science databases, and reference lists of relevant manuscripts. RESULTS Of 1224 screened studies, 43 were included. Over 85% were from predominantly European ancestry populations, and only 22 studies (51.2%) calculated a BDR cutoff based on a healthy control group. Five studies included triplicate testing with a placebo to account for the within-subject intrasession repeatability. A relative BDR was most consistently reported by the included studies (95%) but varied widely across all techniques. Various statistical methods were used to define a BDR, with six studies using receiver operating characteristic analyses to measure the discriminative power to distinguish healthy from wheezy and asthmatic children. CONCLUSION A BDR in 2- to 6-year-olds cannot be universally defined based on the reviewed literature due to inconsistent methodology and cutoff calculations. Further studies incorporating robust methods using either distribution-based or clinical anchor-based approaches to define BDR are required.
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Affiliation(s)
- Matthew D Wong
- Department of Paediatric Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Children's Health and Environment Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Kathleena Condon
- Children's Health and Environment Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Paul D Robinson
- Department of Paediatric Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Children's Health and Environment Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Sadasivam Suresh
- Department of Paediatric Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Children's Health and Environment Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Syeda Farah Zahir
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Peter D Sly
- Children's Health and Environment Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Tamara L Blake
- Children's Health and Environment Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
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Meoli A, Trischler J, Hutter M, Dressler M, Esposito S, Blümchen K, Zielen S, Schulze J. Impulse oscillometry bronchodilator response in preschool children. Pediatr Pulmonol 2024; 59:1321-1329. [PMID: 38353391 DOI: 10.1002/ppul.26909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 01/03/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND In preschoolers, performing an acceptable spirometry and measuring bronchodilator response (BDR) is challenging; in this context, impulse oscillometry (IOS) represents a valid alternative. However, more studies on the standardization of BDR for IOS in young children are required. OBJECTIVE The objective of the study was to identify optimal thresholds to define a positive BDR test with IOS in preschoolers with suspected asthma. METHODS Children aged 3-6 years with suspected asthma and their lung function investigated with both IOS and spirometry pre- and post-BDR were retrospectively analyzed. The spirometric BDR was defined as positive when the change of FEV1 was ≥12% or ≥200 mL. The oscillometric BDR was defined as positive in case of change of at least -40% in R5, +50% in X5, and -80% in AX. RESULTS Among 72 patients, 36 (age 5.2 ± 1 years; 64% boys) were selected for the subsequent analysis according to ATS/ERS quality criteria of measurements; specifically, 19 patients did not meet IOS and 36 did not meet spirometry criteria. The spirometric BDR was found positive in seven subjects (19.4%); conversely, a positive oscillometric BDR was identified in four patients (11.1%). No patient presented a positive BDR response with both methods. In IOS, the mean decrease in R5 and AX was 19.9% ± 10% and 44% ± 22.1%, and the mean increase in X5 was 23.3% ± 17.8%, respectively. A decrease in R5 of 25.7% (AUC 0.77, p = .03) and an increase in X5 of 25.7% (AUC 0.75, p = .04) showed the best combination of sensitivity and specificity to detect an increase of FEV1 ≥ 12% and/or ≥200 mL. CONCLUSION The IOS represents a valid alternative to spirometry to measure BDR in preschool children and should be the gold standard in this age group. We are considering a decrease of 26% in R5 and an increase of 26% in X5 as diagnostic threshold for BDR.
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Affiliation(s)
- Aniello Meoli
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic fibrosis, Frankfurt am Main, Germany
- Department of Medicine and Surgery, Pediatric Clinic, University Hospital of Parma, Parma, Italy
| | - Jordis Trischler
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic fibrosis, Frankfurt am Main, Germany
| | - Martin Hutter
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic fibrosis, Frankfurt am Main, Germany
| | - Melanie Dressler
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic fibrosis, Frankfurt am Main, Germany
| | - Susanna Esposito
- Department of Medicine and Surgery, Pediatric Clinic, University Hospital of Parma, Parma, Italy
| | - Katharina Blümchen
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic fibrosis, Frankfurt am Main, Germany
| | - Stefan Zielen
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic fibrosis, Frankfurt am Main, Germany
| | - Johannes Schulze
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic fibrosis, Frankfurt am Main, Germany
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Wong MD, Blake TL, Zahir SF, Suresh S, Hantos Z, Grimwood K, Lambert SB, Ware RS, Sly PD. Longitudinal tracking of intrabreath respiratory impedance in preschool children. Pediatr Pulmonol 2024. [PMID: 38560779 DOI: 10.1002/ppul.26994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 03/06/2024] [Accepted: 03/18/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Longitudinal measurements of intrabreath respiratory impedance (Zrs) in preschool-aged children may be able to distinguish abnormal lung function trajectories in children with a history of wheezing compared to healthy ones. METHODS Children from a prospective, longitudinal community-based cohort performed annual intrabreath oscillometry (IB-OSC) measurements from age 3- to 7-years. IB-OSC was performed using a single 10 Hz sinusoid while clinically asymptomatic. Linear mixed-effects models were developed to explore the effects of wheezing phenotypes, growth, and sex on seven IB-OSC outcome variables over time: resistance at end-expiration (ReE), resistance at end-inspiration (ReI), the tidal change in resistance (∆R=ReE-ReI), reactance at end-expiration (XeE), reactance at end-inspiration (XeI), the tidal change in reactance (∆X=XeE-XeI), and ∆X normalized by tidal volume (∆X/VT). RESULTS Eighty-five children produced 374 acceptable IB-OSC measurements. Subjects were classified into one of three wheeze groups: never (n = 36), transient (n = 34), or persistent (n = 15). After adjusting for height, children with persistent wheezing, compared to those who never wheezed, had +0.814 hPa s L-1 ReE (95% confidence interval [CI] +0.178 to +1.451, p = 0.015), -0.792 hPa s L-1 XeE (95% CI -1.203 to -0.381, p = 0.003), -0.538 hPa s L-1 ∆X (95% CI -0.834 to -0.242, p = 0.007) and -1.672 hPa s L-2 ∆X/VT (95% CI -2.567 to -0.777, p < 0.001). Increasing height had a significant effect on all IB-OSC resistance and reactance variables when adjusted for the effect of preschool wheezing. CONCLUSIONS IB-OSC is feasible for tracking lung function growth in preschool-aged children and may allow abnormal lung function to be identified early in asymptomatic preschoolers with a history of persistent wheezing.
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Affiliation(s)
- Matthew D Wong
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - Tamara L Blake
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - Syeda F Zahir
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
| | - Sadasivam Suresh
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Zoltán Hantos
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Keith Grimwood
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Departments of Infectious Disease and Paediatrics, Gold Coast Health, Southport, Queensland, Australia
| | - Stephen B Lambert
- The University of Queensland Centre for Clinical Research, Herston, Queensland, Australia
- National Centre for Immunisation Research and Surveillance, Westmead, New South Wales, Australia
| | - Robert S Ware
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Peter D Sly
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
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Hawkins R, Morton R, Eid N, Bickel S. Impulse Oscillometry: Where Are We Now? PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2023; 36:127-129. [PMID: 38134317 DOI: 10.1089/ped.2023.0149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Affiliation(s)
- Rose Hawkins
- Division of Pulmonology, Allergy and Immunology, University of Louisville, Norton Children's and University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Ronald Morton
- Division of Pulmonology, Allergy and Immunology, University of Louisville, Norton Children's and University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Nemr Eid
- Division of Pulmonology, Allergy and Immunology, University of Louisville, Norton Children's and University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Scott Bickel
- Division of Pulmonology, Allergy and Immunology, University of Louisville, Norton Children's and University of Louisville School of Medicine, Louisville, Kentucky, USA
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Chawes B, Elenius V. Pulmonary function testing for the diagnosis of asthma in preschool children. Curr Opin Allergy Clin Immunol 2022; 22:101-106. [DOI: 10.1097/aci.0000000000000815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kulkarni S, Kurane A, Sakate D. Impulse Oscillometry System for the Diagnosis of Wheezing Episode in Children in Office Practice. J Asthma Allergy 2022; 15:353-362. [PMID: 35320988 PMCID: PMC8935627 DOI: 10.2147/jaa.s344643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Objective Objectively differentiating between wheezing episodes and other respiratory disorders will be helpful in treatment in office practice. The impulse oscillometry system has been useful in assessing airway resistance in children 3–6 years old. As the reference values are different in geographical regions the use of the impulse oscillometry is still limited. Comparison between the percent change in IOS parameters as compared to reference standards and changes in actual IOS parameters was done to diagnose wheezing episodes. Methodology Three to six years old children with a history of fever, cough, cold, and/or breathlessness with noisy breathing and who were not on any regular medications, whose parents gave consent were recruited in the study. The children underwent an impulse oscillometry system examination as per the guidelines. The test was repeated after they were given nebulization by salbutamol (2.5 mg) (before COVID 19 pandemic). Final diagnosis was done by following patients for 7 days. Results About 106 children were recruited in the study. Five children could not perform the IOS test. Eighteen children did not complete the follow-up. Hence, 83 children were analyzed. There were 47 males and 36 female patients. The change in actual values of AX, R5, and X20 showed statistically significant difference in wheezing episode group (p-value<0.001). The percentage change as compared to predicted values of R5 and X20 also showed a statistically significant difference in the wheezing episode group and the others group (p-value<0.001). Conclusion The change in actual values of AX, R5, X20, and resonant frequency may help to differentiate wheezing episode from other respiratory diseases.
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Affiliation(s)
- Suhas Kulkarni
- Department of Pediatrics, D.Y. Patil Medical College, Kolhapur, Maharashtra, India
- Correspondence: Suhas Kulkarni, D.Y. Patil Medical College, Kolhapur, Maharashtra, India, Tel +91 231 2601235, Fax +91 231260138, Email
| | - Anil Kurane
- Department of Pediatrics, D.Y. Patil Medical College, Kolhapur, Maharashtra, India
| | - Deepak Sakate
- Department of Statistics and Applied Mathematics, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India
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Elenius V, Chawes B, Malmberg PL, Adamiec A, Ruszczyński M, Feleszko W, Jartti T. Lung function testing and inflammation markers for wheezing preschool children: A systematic review for the EAACI Clinical Practice Recommendations on Diagnostics of Preschool Wheeze. Pediatr Allergy Immunol 2021; 32:501-513. [PMID: 33222297 DOI: 10.1111/pai.13418] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/06/2020] [Accepted: 11/13/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Preschool wheeze is highly prevalent; 30%-50% of children have wheezed at least once before age six. Wheezing is not a disorder; it is a symptom of obstruction in the airways, and it is essential to identify the correct diagnosis behind this symptom. An increasing number of studies provide evidence for novel diagnostic tools for monitoring and predicting asthma in the pediatric population. Several techniques are available to measure airway obstruction and airway inflammation, including spirometry, impulse oscillometry, whole-body plethysmography, bronchial hyperresponsiveness test, multiple breath washout test, measurements of exhaled NO, and analyses of various other biomarkers. METHODS We systematically reviewed all the existing techniques available for measuring lung function and airway inflammation in preschool children to assess their potential and clinical value in the routine diagnostics and monitoring of airway obstruction. RESULTS If applicable, measuring FEV1 using spirometry is considered useful. For those unable to perform spirometry, whole-body plethysmography and IOS may be useful. Bronchial reversibility to beta2-agonist and hyperresponsiveness test with running exercise challenge may improve the sensitivity of these tests. CONCLUSIONS The difficulty of measuring lung function and the lack of large randomized controlled trials makes it difficult to establish guidelines for monitoring asthma in preschool children.
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Affiliation(s)
- Varpu Elenius
- Department of Pediatrics, Turku University Hospital and Turku University, Turku, Finland
| | - Bo Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Pekka L Malmberg
- The Skin and Allergy Hospital, University of Helsinki, Helsinki, Finland
| | - Aleksander Adamiec
- Department of Pediatrics, Medical University of Warsaw, Warsaw, Poland.,Department of Pediatric Pneumology and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Marek Ruszczyński
- Department of Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Wojciech Feleszko
- Department of Pediatric Pneumology and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Tuomas Jartti
- Department of Pediatrics, University of Oulu and Oulu University Hospital, Oulu, Finland
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Lundblad LKA, Blouin N, Grudin O, Grudina L, Drapeau G, Restrepo N, Ducharme FM. Comparing lung oscillometry with a novel, portable flow interrupter device to measure lung mechanics. J Appl Physiol (1985) 2021; 130:933-940. [PMID: 33539262 DOI: 10.1152/japplphysiol.01072.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In the community setting, assessing spirometry in school-aged children is often limited by the unavailability of respirology technicians at the point-of-care. We developed a new technique called the Rapid Expiratory Occlusion Method (REOM) that measures respiratory resistance during normal breathing, without specialized training. The aim was to examine the concordance between respiratory resistance measured with the REOM and respiratory resistance measured by oscillometry on the tremoflo. Children aged 6-17 yr, with or without asthma, received respiratory resistance testing on the tremoflo, then on the REOM. Three to five replicates with a coefficient of variation ≤15% were obtained on each instrument; the primary outcome was the concordance between the average respiratory resistance on the REOM and that measured at 5 Hz (R5) on the tremoflo. Thirty-two children (11 girls; 21 boys) were enrolled with a mean age of 11.2 (range 6-17) yr; after excluding two children not meeting reproducibility criteria, 9 healthy controls, 15 controlled asthmatics, and 6 poorly controlled asthmatics were included. Resistance measured on the REOM showed a strong correlation with R5 measured on the tremoflo (P < 0.0001) with no significant differences on the Bland-Altman analyses. Children and their parents found the REOM easy to use and would consider for home use if recommended by their doctor. With the high concordance between resistance values measured on the REOM and that on the tremoflo combined with perceived ease of use, the REOM appears as a promising means for measuring lung function, thus supporting further testing of other psychometric properties.NEW & NOTEWORTHY We have developed a novel version of the interrupter technique to measure respiratory resistance. The Rapid Expiratory Occlusion Method (REOM) is a small handheld device that measures respiratory resistance and demonstrates excellent correlation with airway oscillometry. With its ease of use, REOM may be promising for use in community practice, patient's homes, and, if paired with a telemedicine application, could enable the healthcare provider to monitor patients in their homes.
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Affiliation(s)
- Lennart K A Lundblad
- Meakins-Christie Laboratories, McGill University, Montreal, Quebec, Canada.,THORASYS Thoracic Medical Systems Inc., Montreal, Quebec, Canada
| | - Nicolas Blouin
- Clinical Research on Childhood Asthma Research Unit, Research Centre, Sainte-Justine University Health Centre, Montreal, Quebec, Canada
| | - Oleg Grudin
- Spirotech Medical Inc., Montreal, Quebec, Canada
| | - Lyudmila Grudina
- THORASYS Thoracic Medical Systems Inc., Montreal, Quebec, Canada
| | - Guy Drapeau
- THORASYS Thoracic Medical Systems Inc., Montreal, Quebec, Canada
| | - Natalia Restrepo
- THORASYS Thoracic Medical Systems Inc., Montreal, Quebec, Canada
| | - Francine M Ducharme
- Clinical Research on Childhood Asthma Research Unit, Research Centre, Sainte-Justine University Health Centre, Montreal, Quebec, Canada.,Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada.,Depatment of Social and Preventive Medicine, University of Montreal, Montreal, Quebec, Canada
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Jartti T, Liimatainen U, Xepapadaki P, Vahlberg T, Bachert C, Finotto S, Kowalski ML, Sobanska A, Lukkarinen H, Pasioti M, Vuorinen T, Zhang N, Zimmermann T, Papadopoulos NG. Clinical correlates of rhinovirus infection in preschool asthma. Allergy 2021; 76:247-254. [PMID: 32621330 PMCID: PMC7818397 DOI: 10.1111/all.14479] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/06/2020] [Accepted: 06/16/2020] [Indexed: 12/15/2022]
Abstract
Background Investigation of preschool asthma is important since not all children outgrow their illness during this age. Data are scarce on the role of rhinovirus (RV) infections in this patient group. Objectives To investigate the role of RV infections in preschool asthma: (i) susceptibility factors, (ii) clinical course, and (iii) medium‐term outcome. Methods A total of 130 asthmatic children aged 4‐6 years from the multinational PreDicta cohort were prospectively followed for a 12‐month period. Allergy tests and a standard health questionnaire were carried out at study entry. Respiratory virus presence in nasopharyngeal washes was studied at illness visits and at 3 scheduled visits. Results At study entry, mean age of the children was 5.3 years. Of 571 visits, 54% were positive for any virus and 39% for RV. Patient characteristics were only assessed with RV infection due to low number of other viruses. The use of supplementary vitamin D was inversely associated with RV infection (P < .05). RV infection was associated with more severe course of acute illness in terms of more severe nighttime coughing, more sleep disturbances, and more days with runny nose (all P < .05). RV infection was also associated with more severe disease course during the 12‐month follow‐up in terms of more nights with awakenings and more days of exercise‐related symptoms (both P < .05). Conclusions Vitamin D supplementation may have an anti‐rhinovirus effect. Both short‐ and medium‐term outcomes suggest RV infection to be an important clinical marker of instable preschool asthma.
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Affiliation(s)
- Tuomas Jartti
- Department of Pediatrics and Adolescent Medicine Turku University Hospital and University of Turku Turku Finland
| | - Unna Liimatainen
- Department of Pediatrics and Adolescent Medicine Turku University Hospital and University of Turku Turku Finland
| | - Paraskevi Xepapadaki
- Allergy Department 2nd Pediatric Clinic National and Kapodistrian University of Athens Athens Greece
| | - Tero Vahlberg
- Department of Biostatistics University of Turku Turku Finland
| | - Claus Bachert
- Upper Airway Research Laboratory Ghent University Hospital Ghent Belgium
| | - Susetta Finotto
- Department of Molecular Pneumology Friedrich‐Alexander‐Universität Erlangen‐Nürnberg Universitätsklinikum Erlangen Erlangen Germany
| | - Marek L Kowalski
- Department of Immunology, Rheumatology and Allergy Central University Hospital Lodz Poland
| | - Anna Sobanska
- Department of Immunology, Rheumatology and Allergy Central University Hospital Lodz Poland
| | - Heikki Lukkarinen
- Department of Pediatrics and Adolescent Medicine Turku University Hospital and University of Turku Turku Finland
| | - Maria Pasioti
- Allergy Department 2nd Pediatric Clinic National and Kapodistrian University of Athens Athens Greece
| | - Tytti Vuorinen
- Department of Clinical Microbiology Turku University Hospital and Institute of Biomedicine University of Turku Turku Finland
| | - Nan Zhang
- Upper Airway Research Laboratory Ghent University Hospital Ghent Belgium
| | - Theodor Zimmermann
- Department of Pediatrics and Adolescent Medicine Department of Allergy and Pneumology Children's Hospital Friedrich‐Alexander‐Universität Erlangen‐Nürnberg Universitätsklinikum Erlangen Erlangen Germany
| | - Nikolaos G Papadopoulos
- Allergy Department 2nd Pediatric Clinic National and Kapodistrian University of Athens Athens Greece
- Division of Infection, Immunity & Respiratory Medicine University of Manchester Manchester UK
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